Complaint·June 17, 2024

On 07/07/2023 LPA Lopez conducted interviews with two staff members between 11:55 AM and 1:54 PM. On 05/07/2024 LPAs Esther Cortez and Sandra Urena conducted interviews and observed resident rooms. During today's visit LPA Cortez conducted a record review and staff interview. Staff did not safe guard resident's personal supplies. On the allegation that Staff did not safeguard resident's personal supplies, the reporting parties concern is that a family member and the hospice nurse witnessed staff #2 (S2) come into Resident’s #1 (R1’s) room, take incontinence supplies and leave. To investigate the allegation, interviews were conducted. Interviews with S2, conducted on 07/07/23, revealed that S2 admitted to taking some of R1’s incontinent supplies and stated they knew it was wrong, and that they were in a hurry to assist other residents who needed to be changed. The staff stated a home health nurse observed them take the supplies and said they returned them when confronted. The staff stated this happened only one time. There is sufficient evidence to support the allegation of Staff did not safeguard resident's personal supplies. Therefore, the above allegation is deemed Substantiated at this time. Staff did not provide resident / resident's authorized person copies of requested records. On the allegation that Staff did not provide resident / resident's authorized person copies of requested records, the reporting parties concern is that on numerous occasions R1’s records were requested by the resident and or resident’s authorized person and not provided. It was further reported that when the records were provided, they were not complete, specifically documentation of R1’s fall on 12/30/22 was not provided along with other documents. To investigate the allegation, record review and interviews were conducted. Information obtained revealed that on 02/01/2023 (previous) Administrator Jill Ford received and signed a request for R1’s records, including but not limited to personal and clinical records to be release to R1’s authorized person. On 02/27/2023, the facility received a second medical record request from R1’s authorized person. In addition, information obtained revealed that R1’s authorized person made contact with Administrator Jill Ford via email regarding R1’s records request on 03/26/23, 04/02/23, 04/21/23, 05/06/23, 05/07/23, 05/14/23 and on 05/15/23. On or about 05/15/23, R1’s records were issued to R1’s authorized person, however it was reported to the interim Administrator Julius Osorio on 05/31/23 that the records were incomplete, particularly regarding a fall R1 sustained on 12/30/22. Report will continue on LIC9099-C (3RD PAGE). In 2023 Sage Mountain Senior living transitioned from Milestone management company to Agemark management company. Interview with Julius Osorio, who was the interim Administrator during June of 2023, revealed that they received notification from R1’s authorized person on 05/31/23 via email that R1’s records were incomplete, however all the records that were provided were the same records Agemark had on file. Osorio revealed that R1’s authorized person had been informed Agemark would not have access to digital records once they took over and records would need to be requested through Milestone. It was further revealed that Osario did not verify if R1’s authorized person had received the requested missing documentation as they assumed Milestone would be handling it through their team. Record review revealed that there was no record of an incident report completed for R1’s fall on 12/30/22. Based on the information obtained, the Department found sufficient evidence to support the allegation, Staff did not provide resident / resident's authorized person copies of requested records. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.