complaint·September 19, 2024

Complaint alleges that Resident are not receiving enough hydration. Based on interviews and observations that were conducted throughout the course of the investigation, LPA could not corroborate the allegation. Furthermore, LPA interviewed Resident #1 and learned that staff are attentive to the needs of the resident, and that the residents get plenty of food and water at the facility. Complaint alleges Staff are doing finger sticks to check blood sugars. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. LPA learned that residents are assisted with checking of blood sugars which was confirmed by interviews with Former Staff Member #1, and the current Administrator of the facility. Complaint alleges that Medications have been charted as given but have not been. Based on observations of the Medication Administration Record (MAR) on August 27, 2024, LPA observed that medications have been charted appropriately. Furthermore, LPA did not have sufficient evidence to corroborate the allegation. Complaint alleges that Narcotics have been missing. Based on an interview that was conducted with Witness #1, LPA learned that a narcotic was missing on August 8, 2024, and documented in the Hospice Nurses Notes. However, the narcotics medications were found by the facility and not missing. On August 27, 2024, during the opening of the complaint, LPA reviewed the Medication Administration Record (MAR) for Resident #3 and observed the medication in question to be available, secured, and locked. LPA did not have sufficient evidence to corroborate the allegation. Complaint alleges that Staff do not check on resident's oxygen equipment at night, putting her at risk. Based on interviews that were conducted, LPA received inconsistent statements as it relates to the allegation. Furthermore, LPA could not corroborate the allegation. Complaint alleges that Staff did not refill resident’s medication prescription. Based on observations and interviews, LPA reviewed the Medication Administration Record (MAR) for Resident #1, #2 and #3 on August 27, 2024, and did not observe any concerns. LPA conducted interviews and received inconsistent statements during the interviews. LPA did not have sufficient evidence to corroborate the allegation. (Report continued on LIC 9099C) Complaint alleges that staff was tested covid positive. Based on interviews that were conducted, LPA learned that the facility followed their respective Infection Control Plan and kept the staff member at home. Furthermore, LPA received inconsistent statements as it relates to the allegation. LPA did not have sufficient evidence to corroborate the allegation. A finding that the complaint allegations of Residents are not being changed in a timely manner, Resident are not receiving enough hydration, Staff are doing finger sticks to check blood sugars, Medications have been charted as given, but have not been, Narcotics have been missing, Staff do not check on resident's oxygen equipment at night, putting her at risk, Staff did not refill resident’s medication prescription, Staff was tested covid positive are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. Complaint alleges that Resident left on commode for long periods of time. Based on interviews that were conducted on August 27, 2024 with the Administrator, LPA learned that the former staff member accidentally left the resident on the commode for approximately 20 minutes. During an interview with the former staff member on September 12, 2024, at approximately 12:00 PM, LPA learned that the resident was left on the commode for 15 minutes. Former Staff Member was able to acknowledge this incident and was apologetic to the facility Administrator and to the LPA (See LIC 9099D). Complaint alleges that Staff did not charge resident’s oxygen tank. Based on interviews that were conducted with the Administrator on August 27, 2024, LPA learned that the resident’s oxygen tank was not plugged in all the way which subsequently led to the oxygen not dispensing to the resident (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that all oxygen devices are functioning and operating normally. Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.