Complaint·March 26, 2025

LPA Marrufo obtained a copy of R1’s Appraisal/Needs and Services Plan (A/NS), dated 08/09/2024. The “Background Information” section of the A/NS states “with assistance with [his/her] ADLs (Activities of Daily Living) and Transfers.” The Functioning Skills section states “[R1] is independent.” The A/NS does not include details of R1’s needs related to ADLs, transfers, special diet, and feeding. R1’s A/NS Plan was signed by the facility Administrator/Licensee on 08/09/2024. The signature fields for the client/resident’s authorized representative are blank. LPA Marrufo obtained copies of R1’s Progress Notes written by R1’s Speech Therapist. The Progress Note from 08/16/2024 states “Avoid bread items, except for very soft and moist textures like banana bread cut on to bite size.” The Progress Note from 08/28/2024 states “Pls (sic) provide feeding assistance & offer water every hour until pt can feed [him/her]self independently.” The Progress Note from 09/06/2024 states, “Downgrade diet level to soft + bite sized texture as pt eats alone sometimes & pt may self-feed large bites w/o supervision. ** No Bread.” The Progress Note from 09/16/24 states, “Pls make sure to avoid bread items – pancakes, toast, etc.” The Progress Note from 10/04/2024 at 11:10 states, “Pls make sure pt receiving safe & bite-sized texture only. Pt choked today. It can happen again. Avoid all breads. Pls refer to the soft & bite-sized handout if needed.” During visit on 10/11/2024, LPA Marrufo interviewed R1. R1 stated to not have a special diet. R1 stated R1 requires food to be soft. R1 stated R1 likes food to be textured but does not require it to be. R1 stated staff always provide R1 with soft and textured food. R1 stated that R1 has chocked on food while at the facility. R1 stated to have chocked on big chunks of apple pie with a “rustic crust.” R1 stated R1’s speech therapist fed R1 the apple pie. R1 stated the speech therapist is not a staff of the facility. R1 stated the speech therapist feeds R1 to check R1’s swallowing and chewing. R1 stated the apple pie came from the facility kitchen. R1 states to not know why the staff did not cut up the apple pie into smaller pieces. During interview on 10/11/2024, facility manager M1 stated that R1 had a choking incident on 10/04/2024 at noon during lunch. M1 stated that R1’s meal came from the facility kitchen. M1 stated neither M1 nor the facility staff were told that R1’s Speech Therapist would be feeding R1. M1 stated R1’s order for soft and textured food came from home health and the facility does not have R1’s home health plan. M1 stated R1 is a manual feeder and can feed himself/herself independently. Page 2 of 5. M1 stated that R1’s Speech Therapist was feeding R1 and called the staff to let them know R1 was choking. M1 stated R1’s Speech Therapist called 911. M1 stated that when the paramedics arrived, they determined R1 was stable and did not want to take R1 to the emergency room. During interview on 10/11/2024, staff S1 stated that R1 needs bite-sized foods. S1 stated that R1’s Speech Therapist told S1 that R1 requires bite-sized food when R1 was admitted to the facility. S1 stated that S1 made notes in the kitchen that R1 needs bite-sized food. S1 stated that S1 uses a cutter to cut R1’s food and that when R1’s food leaves the kitchen, it is already cut to bite-size. S1 stated to have not observed R1 choking on food. S1 stated R1’s Speech Therapist reported to S1 that R1 was choking on R1’s food. S1 stated to have asked R1's Speech Therapist that if R1 was choking, then why was R1’s plate empty? S1 stated to have checked R1’s vitals and found R1’s vitals to be normal. S1 stated R1’s Speech Therapist called 911. During interview on 03/26/2025, R1’s Speech Therapist stated that R1’s home health plan was not at the facility. R1’s Speech Therapist stated that he/she would write Progress Notes after each visit with R1 and review the Progress Notes with the staff. R1’s Speech Therapist stated to have left a handout with staff that explained what kind of food qualified as bite-sized and soft. R1’s Speech Therapist stated that bite-sized food would be around the width of the average person’s thumb and soft food would be food that could be squished by placing a fork over the food and applying thumb pressure on top of the fork. If the fork can squish the food, then the food is considered soft. If not, then the food would be considered too hard and would need to be cooked further. R1’s Speech Therapist stated that he/she was in R1’s bedroom when R1 choked. He/she stated there were no staff in the room with him/her at that time. He/she stated that R1 was feeding himself/herself. R1’s Speech Therapist stated that R1 may have been eating either a spring roll or an apple pie, although he/she could not remember exactly. R1’s Speech Therapist stated R1 began to choke and he/she began to tell R1 to cough hard to clear R1’s throat. R1’s Speech Therapist stated no staff were nearby, so he/she decided to call 911 for R1. He/she stated that when paramedics arrived, R1 refused to go be taken to the hospital. Page 3 of 5. R1’s Speech Therapist stated that apple pie may or may not be considered soft food, depending on whether the apples are crispy or soft and if the crust can be crushed by a fork easily. During visit on 10/11/2024, LPAs Fortes and Marrufo observed R1 feeding himself/herself with a spoon that had an assistive foam grip while sitting in a wheelchair. R1 was observed to be eating ravioli and garlic bread that was cut into small pieces. During interview on 10/11/2024, R1 stated that staff transfer R1 out of bed and into R1’s wheelchair three times a day for meals. R1 stated that if R1 wishes to be transferred out of bed at other times, staff transfer R1 out of R1’s bed. R1 stated staff use a Hoyer lift to transfer R1 out of bed. R1 stated to have never been left in bed all day. During interview on 10/11/2024, M1 stated that R1 is never left in bed all day. During visit on 10/11/2024, LPAs interviewed 3 staff. 3 out of the 3 staff stated they assist R1 with transferring from R1’s bed to R1’s wheelchair. LPAs obtained copies of R1’s Wheelchair Transfer Record for September 2024 and October 2024. The logs record the times R1 was transferred to R1’s wheelchair in the morning, afternoon, and evening. Each day indicates R1 was either transferred twice in each morning, afternoon, and evening or refused to be transferred except on the evenings of 09/24-26/2024, which are blank. The October 2024 log has blank spaces on the evenings of 10/03-04/2024 and 10/08-11/2024 and the afternoons of 10/04/2024 and 10/9-11/2024. The rest of the times indicate either staff transferred R1 or R1 refused to be transferred. During interview on 03/26/2025, M1 stated that the blank spaces on the Wheelchair Transfer Logs must have been times when R1 was sleeping. M1 stated to have told the staff to write in the Remarks column of the Wheelchair Transfer Logs when the resident was sleeping, but the staff may not have written that R1 was sleeping. Page 4 of 5. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Michael Rosete and a copy of this report was provided. Page 5 of 5. END REPORT During interview on 03/26/2025, M1 stated to have called pest control on 10/11/2024 and pest control specialists visited the facility on the following Saturday. LPA obtained copies of the Pest Control Invoice that indicates pest control specialists arrived at the facility on 10/12/2024 to spray for cockroaches. On 10/11/2024, LPAs interviewed 3 other staff. 3 of the 3 interviewed staff stated to have not observed cockroaches at the facility. On 10/11/2024, LPAs interviewed 6 residents. 2 out of the 6 interviewed residents stated to have observed cockroaches at the facility. 4 out of the 6 interviewed residents stated to have not observed cockroaches at the facility. Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Michael Rosete and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT