Complaint·March 8, 2025

Furthermore, R1 denied the allegations. LPA Lee was unable to obtain a statement from R2, as R2 refused to be interviewed. Due to the lack of documentation and insufficient information, there was no clear indication that the alleged incidents occurred. Based on the interviews and records review during the investigation, LPA Lee was unable to corroborate the allegations. Additionally, it was alleged that staff did not follow resident’s care plan and staff do not provide proper incontinence care to resident in care. This investigation also involved interviews with facility staff and residents. 5 out of 5 staff members denied the allegations. LPA interviewed 2 out of 2 residents; both of whom stated they receive incontinence care from the facility staff. In an interview with R1, R1 confirmed receiving 1:2 assistance with transferring. A review of R1’s LIC 602 Physician’s Report does not indicate the need for 1:2 assistance; however, R1's LIC 625 Needs and Services Plan states that R1 requires 1:1 assistance if using a Hoyer lift or 1:2 assistance if using a person lift. According to R2’s LIC 602 Physician’s Report and LIC 625 Needs and Services Plan, R2 does not require 1:2 assistance. Based on facility notes, residents' briefs are being checked and changed as needed. Based on the interviews and records review during the investigation, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided. Exit interview. Furthermore, R2’s medications were not initialed as administered on 11/22/24. The CSMD did not match the MAR log. Additionally, some medications were listed on the MAR log but were missing from the CSMD records. • Resident 2 (R2): Three medications were listed on the MAR logs; however, they were not present in the facility. Several medications were not initialed to indicate administration, and the CSMD did not align with the MAR log. Additionally, multiple medications were listed on the MAR log but were not documented on the CSMD. Medications observed in R1's medication box were not listed on the MAR log, though they were found in the CSMD. • Resident 3 (R3): Medications found in the resident’s medication box were not listed on the MAR log, though they were recorded on the CSMD. Also, medications on the MAR log were not present in the medication box. The Med-tech explained that the missing medications were discontinued; however, the MAR log did not reflect this discontinuation. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.