Complaint·July 5, 2023

Based on documentation provided by the facility, R1 has a physician's order for mechanical soft diet, however, R1 was served raw bell peppers, and raw onions and R1 has provided written communication to facility directors reporting this incident. According to facility Chef, he/she and the memory care director met with R1 on 5/18/2023 to reviewed R1's food preferences and improvements have been made. According to facility staff, R1 has received food items that R1 was not able to chew and alternates were given upon R1's request. After the investigation, this allegation is deemed to be substantiated as R1 was served a diet that was not prescribed by the physician. Regarding to allegation of facility did not respond to resident's emergency cord, the reporting party stated on 4/20/2023 early morning, R1's roommate resident #2 (R2) fell and R1 pressed multiple call cords in the room, however, it was not responded by staff resulted R1 who has unsteady gait assisted R2 back into the bed. As part of the investigation, LPA interviewed R1, interviewed administrator, and reviewed facility records. R1 stated that on 4/20/2023 around 5- 6am, R1's roommate fell and R1 pressed the call cords in the room but no one came; R1 went outside of the room pleading for assistance but no one was around so R1 had to assist R2 back to bed. According to the Device Activity Report(this report reveals the call cord response time) that was provided by the facility, it revealed that on 4/20/2023, call cord was activated in R1 and R2's room at 5:53AM and the reset time was 205 minutes and 46 seconds and according to the administrator, the reset time was the time when staff answered the call cord and reset it. Furthermore, LPA observed on the same report that another apartment on 5/3/2023, call cord was activated at 2:32 AM and the reset time was 210 minutes and 42 seconds. After the investigation this allegation is deemed to be substantiated. In addition, a separate deficiency will be issued on a LIC 809 (Case Management Report) as facility staff failed to assist R2 back to bed after the fall. Based on interviews, observations and record review during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, A copy is provided and Appeal Rights provided. According to R1, it was difficult to get laundry services in the beginning of R1's stay but now R1 prefers to have the weekly laundry service that is provided by someone from an agency. According to the memory care director and the former administrator, R1's laundry services is provided by someone who comes in once a week but facility will do it if needed as indicated on R1's individual service plan. Based on interviews, observations and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated. This report is reviewed and discussed with the administrator. A copy is provided.