complaint·January 28, 2025

LPA asked R1 if the facility staff remind them to put it back on. R1 exclaimed "oh yeah, they remind me all the time." R1 stated that they did not have their oxygen tank when they moved to their temporary room. R1 stated that they could not remember how many days they did not have their oxygen. R1 further stated that the staff probably forgot about it, since R1 never mentioned it to them. LPA interviewed outside agency (OA) who stated that R1 arrived at the emergency room with a low oxygen saturation. OA stated that R1 is required to be on oxygen 24/7.OA stated that the facility was treating R1's room for bed bugs and as a result, R1 was transferred to a different room. OA further stated that staff member 1 (S1) advised OA that R1 was moved to their temporary room without their oxygen tank. S1 further stated that since the room was being treated, staff could not enter the room to retrieve it. OA believes R1 was without their oxygen tank for several days. LPA interviewed R1's responsible party (RP) who stated that R1 has lived at the facility approximately four years. RP stated that R1 is a "pain" and stubborn. RP stated that R1 regularly goes against doctor's orders and refuses to wear compression socks and removes their oxygen regularly. RP stated that R1 will throw staff out of R1's room although they are just trying to help. LPA interviewed S1 who stated that they "do not know what happened" in regards to R1's oxygen tank. S1 stated that R1's oxygen tank was not with R1 prior to being transported to the hospital. S1 explained that R1's room was being treated for bed bugs and facility staff forgot to move R1's oxygen tank to their temporary room. S1 believes that R1 did not have their oxygen on at the time of the move which caused staff to leave the tank in the room. S1 stated that since the room was being treated for bed bugs staff could not enter the room to retrieve the oxygen tank. S1 estimated that R1 was without their oxygen tank for approximately two days. LPA interviewed staff member 2 (S2) who stated that they assisted in clearing out R1's temporary room. S2 stated that they noticed that R1's oxygen tank was not transferred to the room. S2 stated that R1 was without their oxygen for approximately two days. S2 stated that they believe staff simply "forgot to move it out." LPA interviewed Executive Director (ED) who stated that she was not aware of the incident involving R1 and their oxygen tank until today. ED stated that she was out of the office during that time frame and was not advised by staff of the incident. ED further stated that facility staff should be aware of R1's need for oxygen since R1 has an "oxygen sign" posted outside of their door. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.