complaint·March 4, 2022

It was reported that the facility staff did not follow Resident (R1)’s diabetic dietary plan due to staff feeding R1 high sugar foods such as bananas, apple pie, peanut butter & jelly sandwiches. Interviews determined Administrator bought the food items and staff did not follow R1's dietary plan in which R1 was fed those items on a daily basis because R1 requested it. Administrator stated they wanted to ensure R1's personal rights to choose their food & snack items. However, the facility failed to notify the doctor and it was not approved in R1's diabetic dietary plan. It was alleged the facility did not follow COVID-19 precautions. Based on LPA observations, outside interviews, and facility records, it was revealed that staff did not follow COVID-19 precautions. LPA received corroborating statements from outside resources that staff were observed without wearing masks indoors as required. Records revealed there was a lack of documentation for COVID-19 procedures. Additionally, LPA's temperature was not taken on inspection visit dated 09/02/2021. Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations were found to be SUBSTANTIATED . California Code of Regulations, (Title 22, Division 6 & Chapter 6), are being cited on the attached LIC 9099-D. Appeal Rights Provided. Staff did not dispense medication per physicians orders : There were a lack of witnesses and documentation to corroborate the allegation. LPA reviewed the facility's Centrally Stored Medication log and Medication Administration Record, documentation did not indicate medication was not given as prescribed. Additionally, a statement from R1's hospice agency indicated there were no concerns or evidence to support that staff had not dispensed R1's medication per physician's orders. Staff violated resident's personal rights by bitting resident: LPA did not receive a date or time of which the incident allegedly occurred. There were a lack of witnesses and documentation of any injuries sustained to corroborate the allegation. Resident was not provided water which caused resident to be dehydrated: Interviews revealed staff provide individual water containers for residents to stay hydrated. A lack of witnesses and documentation of dehydration occurring with R1 and LPA did not received a date of when the alleged incident occurred. Staff failed to provide activities for resident in care: Statements received indicated R1 would often watch television shows in their room and did not want to participate in other activities. Staff left resident in wet diapers for extended periods of time: Statements received revealed R1 had a supply of incontinent briefs and would use them. Hospice chart notes did not indicate skin break down or concerns of leaving R1 soiled for extended periods of time. Statements did not corroborate the allegation. Staff failed to seek medical attention for resident in a timely manner: LPA did not receive confirmation of a date or time of which the incident allegedly occurred. Discharge paperwork revealed R1 was seen in March 2021. There were a lack of witnesses and corroborating statements of staff not contacting medical services in a timely manner. Due to the contradicting statements received and lack of witnesses to the incidents alleged, as well as all the information gathered, The Department was not able to corroborate the allegations. LPA has investigated the complaint alleging “Staff did not dispense medication per physicians orders; Staff violated resident's personal rights by bitting resident; Resident was not provided water which caused resident to be dehydrated; Staff failed to seek medical attention for resident in a timely manner; Staff failed to provide activities for resident in care; Staff left resident in wet diapers for extended periods of time”. Although the allegations 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. We have therefore dismissed the complaint. An exit interview was conducted with Madonna Martinez, Administrator whose signature on this form confirms receipt of these documents. No deficiencies cited regarding the above allegations during today’s visit.