complaint·April 12, 2024

LPA Jensen observed a resident with wounds in the memory care unit. LPA Jensen interviewed Staff 1 (S1) and asked what stage resident 1's (R1's) wounds are. S1 advised that R1's home health nurse stated the wounds are unstageable. During the course of an interview with R1, LPA Jensen asked if he was in pain and R1 confirmed he was. LPA Jensen asked if he would like pain medication and he confirmed he would. LPA Jensen reviewed the MAR for R1 and observed that he had a PRN for pain medication that was last administered on 4/4/24 and documented as being "somewhat effective". S1 also confirmed that R1's physician was not contacted to seek more effective pain medication. Technical assistance was provided on Prohibited Health Conditions. The Executive Director agreed that on this day R1 will be sent out for medical attention as he requires a higher level of care for wounds. Based on the LPA Jensen's observation of a resident with a prohibited health condition, soiled undergarments and briefs in resident rooms, call signal logs and a lack of follow up regarding a PRN medication that did not achieve the desired outcome in effectiveness, the allegation of "Staff do not meet resident's needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Citations are being issued pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was provided.