Complaint·December 23, 2024

Interview conducted with staff, potential witnesses and records reviewed revealed the following: R1 moved into this facility on 05/23/2022. A care plan meeting was initiated by facility staff on or about 06/10/2022 and another in 8/2022. Service plans completed by facility staff dated 5/25/2022; 05/31/2022; 09/06/2022; 11/03/2022; 11/30/2022; 03/21/2023 and 05/31/2023 were observed on file and reviewed. The Service Care Plans did not have any signatures to confirm who completed the evaluation and who was present during the evaluations. Potential witness interviewed revealed that beginning 10/2022 – 9/14/2023 several care plan meetings were initiated by R1’s responsible person due to the increasing decline observed in R1’s condition. On or about 07/13/2023, former Executive Director Stephanie Funderburg reported to R1’s responsible person that they would conduct a 72-hour behavioral mapping to address any issues or concerns. No documentation or record of this was found on file. On or around 09/07/2023, R1 was evaluated by Silverado team, and it was agreed to have R1 tested for possible UTI due to the increasing behavioral changes observed. On 09/13/2023, R1 sustained a fall. Interviews conducted revealed that the facility did not follow through with sending labs out for UTI test results. R1's responsible person was informed by former Director of Health Services - Hope Langston that the lab never picked up the urine sample. No further action was taken by facility. On 09/14/2023, R1's responsible person contacted the physician and reported the increased decline observed and current symptoms; R1 was transferred to the nearest ER per physician orders; R1 was admitted to Los Robles Hospital on 09/14//2023 – series of tests were conducted. R1 tested positive for UTI and chest x-ray indicated pneumonia. Based on the above gathered, there is sufficient evidence to support the allegations; therefore allegations “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”; is deemed Substantiated. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies cited (refer to LIC 809-D): Exit interview conducted. A copy of the report and appeal rights provided. Potential witness interviewed reported that R1 was observed in dirty and smelly clothing on several different occasions. Staff interviewed denied allegations and reported that all residents are assisted with dressing when needed. Staff reported that if a resident is observed with soiled clothing staff would attempt to change resident. Staff expressed that residents do have accidents daily and are changed and cleaned when observed. Staff expressed that if a resident becomes combative, they would give resident space and allow resident to calm down and not force resident to change. Staff reported that residents are not left unattended and are checked and cleaned regularly. Facility common areas, and random resident rooms were toured on 9/20/2023; and on 03/29/2024 during the annual inspection. During these visits, random resident rooms and common areas toured did not observe to be unkept and were odor free at time of visits. Other potential witnesses interviewed shared that the facility is kept clean, odor free and facility residents observed in the common areas to be clean and not with soiled clothing. Based on the above gathered, although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegations “Staff left resident in soiled clothing; Staff not keeping resident’s room free from odor and Staff not keeping resident’s room clean” are deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report provided.