Regarding Allegation #1: this investigation revealed based on interviews conducted of facility staff (A1, S2 – S7) corroborated that Resident #1 has a physician specialist that is working to balance the resident’s medication Alprazolam (Xanax) due to the resident’s behavioral disturbances. Facility staff work with the resident’s physician specialist on a weekly basis communicating the resident’s behavior disturbances. Interviews conducted of Residents (R2 – R7) corroborated that the LVN/Med Tech administers their medications; and, they denied being overmedicated while in care. Interviews conducted of Witnesses (W4 – W5) corroborated that they do not agree or observed Resident #1 being overmedicated by facility staff. A review of Resident #1’s “Pre-Placement Appraisal Information” (dated 06/28/22) documented that the resident “needed help with medication”. A review of the resident’s “Physician’s Medication Order” (dated 06/24/22) documented one of the relevant medications prescribed was Alprazolam (Xanax) with “as needed” instructions. A review of the resident’s “Medication Administration Record” for the month of July 2023 documented that the resident was not administered Alprazolam (Xanax) and for the month of August 2023 documented that the resident was administered Alprazolam (Xanax) on 08/25/23 and 08/26/23. Facility staff have confirmed receiving their annual in-service training on the topic of medication administration.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of MEDICATION: Staff are overmedicating resident while in care is found to be UNSUBSTANTIATED.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident's care needs were not met by staff resulting in resident needing to be hospitalized is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on interviews conducted of facility staff (A1, S2 – S7) corroborated that Resident #1 has a 1:1 private care companion 24/7 to assist the resident; especially at night so it’s not so disruptive for the other residents. Resident #1 has a physician specialist working with the resident to balance their medication to ease the resident and make them comfortable. Staff #2 – Staff 7 confirmed that they have received their annual in-service training on the topic of higher level of care. Interviews conducted of Residents (R2 – R7) corroborated that facility staff are meeting the residents’ activities of daily living and do not have areas of concern regarding their needs not being met. Interview of Witness #4 (W4) does not feel that the facility is retaining the resident who requires a higher level of care. Witness #5 has observed facility staff with the resident’s level of care when visiting on a monthly basis. A review of the resident’s “Pre-Placement Appraisal Information” (dated 06/28/22) documented that the resident had moderate to severe limitations due to cognitive impairment with an ambulatory status. A review of

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of LEVEL OF CARE: Facility is retaining a resident with a higher level of care needs is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation revealed that Resident #1 receives a bath based on the bathing schedule. Interviews conducted of facility staff (A1, S2 – S7) corroborated that the resident receives a bath three (3) times a week by the care providers. Staff #2 – Staff #7 confirmed that they have received on-line, hands-on, and shadow training on capacity for resident’s self-care. Interviews conducted of Residents (R2 – R7) corroborated that they have a shower schedule and some of the residents do not require assistance with their hygiene. Interviews conducted of Witnesses (W4 – W5) corroborated that they have not observed the resident to have hygiene issues. A review of the resident’s Physician’s Report (dated 05/26/23) documented under “Capacity for Self-Care” that the resident requires assistance with bathing. RA Ceniceros observed the resident to be clean and free from an odor during a tour of the resident’s private room and observed a full bathroom to accommodate the resident with their hygiene needs.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff do not ensure that resident's hygiene needs are being met while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #5: this investigation revealed based on interviews conducted of facility staff (A1, S2 – S7) corroborated that Resident #1’s clothing is brought by the resident’s Power of Attorney (Witness #4) who provides all the resident’s attire. Facility staff have not received a complaint from a resident’s responsible person regarding a resident’s clothing attire not fitting. Staff #2 – Staff #7 confirmed that they have received their annual in-service training on the topic of personal rights. Interviews conducted of Residents (R2 – R7) corroborated that they have not had an issue with their clothing needs not being met because the facility is not responsible for purchasing their clothing but confirmed that their clothing are always laundered and clean. Interview of Witness #4 confirmed that they are responsible for Resident #1’s clothing attire and

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are not ensuring that resident's clothing needs are being met while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #6: this investigation revealed based on interviews conducted of facility staff (A1, S2 – S7) corroborated that Resident #1 has a family member (Witness #1) and sibling (Witness #4) that visit with the resident; and, facility staff have not received a complaint from the resident’s responsible person or family member that they are not being accorded privacy during their visit with the resident. Executive Director Koul confirmed that Resident #1 has a 1:1 private care provider who stays in the room next door to Resident #1’s room, but visitors are accorded privacy in the resident’s room, lounge room or patio area. Staff #2 – Staff #7 confirmed that they have received their annual in-service training on the topic of personal rights. Interviews conducted of Residents (R2 – R7) corroborated that facility staff accord them privacy whenever they have had visitors come to see them at the facility. A review of the resident’s “Personal Rights” (dated 06/27/22) documented that the resident would be accorded privacy.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Resident is not accorded privacy while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #7: this investigation revealed based on interviews conducted of facility staff (A1, S1 – S7) corroborated that Resident #1 has a 1:1 private caregiver 24/7 to assist the resident. Interviews conducted of Residents (R2 – R7) corroborated that the facility has sufficient staff to meet their needs and have no areas of concern regarding the facility being understaffed. Interview conducted of Witnesses (W4 – W5) confirmed that the facility provides sufficient staffing during which times they have been at the facility. A review of the facility’s Staff Roster & Work Schedules (August 2023) documented that the facility provides sufficient staffing to residents’ ratio.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did

An exit interview has been conducted and a copy of the Complaint Report was provided to the Executive Director/Administrator, Kelley Koul.