On the allegation: Staff did not seek timely medical attention for a resident. It is alleged that the Staff members cleaned the resident who sustained a fall, and the room of the resident before notifying the resident’s family. The allegation states the resident was bruised and bleeding, but Staff did not seek medical treatment for the resident.

Licensing received a timely Incident Report from the facility detailing the events of the fall and injuries to the resident on 07/31/2023. The incident report states that the resident was found in their bed with laceration above the eyebrow, bruising to the right eye, and a small laceration on both arms. The wounds were cleaned by Staff members and pressure was applied to the laceration. The Responsible Party/Power of Attorney for the resident was notified, and the resident was brought to the Emergency Room. In the Emergency Room medical tests were ordered for the resident including a Blood Test, EKG, Chest X-Ray, and a CAT Scan of the Head and Spine. The resident was discharged and returned to the facility with a diagnosis of Closed Head injury requiring the ordering of antibiotics and a follow up visit with the resident’s primary physician within 1 month. On 08/14/2023, LPA received Emergency Department Patient Discharge Instructions for the resident. The antibiotics are listed on the Centrally Stored Medication and Destruction Record kept by the facility for the resident in care. LPA received physician’s notes for the resident that stated to give the resident the antibiotics as ordered and to monitor the resident for worsening symptoms.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Continued on 9099-C

On 08/14/2023, LPA received medication documentation for the resident including the Centrally Stored Medication and Destruction Record, Physician’s notes, Resident Appraisals, Statements of Patient Advocates or Ombudsman, Physician Orders for Residents including Primary & Secondary diagnosis, Advance Health Care Directives, Appraisal Needs & Services Plans, and Pharmacy Delivery Notes. The resident has a diagnosis of Alzheimer’s with Memory Impairments and early Dementia. There is no documented evidence that the resident is being over-medicated, and the documentation shows that the resident has received all ordered medications from a physician on time in the facility.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not have adequate medication training. RP states the staff had to call Licensee Annie for help and RP also assisted the staff with getting Resident 1 (R1) their medications. RP states the staff are not trained to dispense medications and Annie is the only nurse but is not usually there.

On 08/14/2023, LPA collected the following information/documentation pertinent to the complaint allegations regarding Staff member medication training. LPA received Certificates of Completion for Medication Training & the Passing of a Written Medication Administration Test for Staff members. LPA additionally received In-Service Training Logs for Medication Shadowing, Orientation Staff Training on Medication & Policies and Procedures Regarding Medication for all Staff members. On 08/14/2023, LPA received documentation that the Licensee is certified in Basic Life Support (BLS), CPR, AED, First-Aid, American Heart Association Advanced Cardiovascular Life Support Program (ACLS), and Certification as a Registered Nurse (RN) with the California Board of Registered Nursing with an Active Status. LPA received documentation of a Pre-Test administered to all Participants/Staff members prior to medication training, as well as a Post-Test administered upon the completion of medication training by the Staff members. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C

On 08/14/2023, collected the following information/documentation pertinent to the complaint allegations regarding residents in care. LPA received the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care. LPA additionally received physician’s notes for particular residents, Resident Appraisals, Statements of Patient Advocates or Ombudsman, Physician Orders for Residents including Primary & Secondary diagnosis, Advance Health Care Directives, Appraisal Needs & Services Plans, Physicians Reports for Residential Care Facilities For the Elderly (RCFE), Tuberculosis (TB) Screening Results, Identification and Emergency Information, Pharmacy Delivery Notes, and Emergency Department Patient Discharge Instructions. All documentation collected by the LPA showed adequate record keeping standards by the facility. A specific Staff member not knowing when a resident last had a specific medication was not due to inadequate record keeping by the facility.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff locked resident in their room. It is alleged that a witness observed a resident’s room was locked from the inside and Staff member used their fingernail to unlock it from the outside. The allegation states the resident has Alzheimer’s and is unable to unlock or lock a door by themself. The allegation states the witness advised Staff members not to lock the resident in their room again.

On 08/14/2023, the LPA interviewed the resident in question and observed the bedroom of the resident. From interview and observation by the LPA, the resident was a risk for elopement from the facility as well as entering other resident’s bedrooms at night due to a diagnosis of Early Alzheimer’s/Dementia. The doors to each resident’s rooms have key locks on the handle with a locking mechanism on the inside of the room controlled by the resident. The room is only able to be locked from the inside. If the door becomes locked from the inside, the resident can turn the handle to unlock the door from the inside, which prevents the resident from being locked in by Staff members from the outside. No resident nor Staff member stated that the resident was locked in the room by Staff when interviewed by LPA.

Continued on 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff violated resident’s personal rights. It is alleged that a Staff member intimidates residents by standing over them and staring down at them. The allegation also states that the two Licensees frequently yell at, and verbally fight with each other in front of residents.

There is no evidence from interviews with any resident or Staff member of the facility that the two Licensees frequently verbally yell at each other in front of residents or intimidate residents. No resident stated to the LPA that this has occurred in the facility, and no Staff member acknowledged these actions occurring in front of residents, in the facility, or in general in any location. In multiple physical visits to the facility on 07/31/2023, 08/14/2023, and 08/28/2023, LPA has never observed the two Licensees engaging with each other or residents in a negative manner.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff do not provide residents with adequate food service. It is alleged that one resident has lost 20 pounds since living at the facility. The allegation states that the meals used to be good but the two Licensees are now separated and the husband is no longer the cook, so the meals are given “haphazardly” and with not much variety.

On 07/18/2023, the LPA visited the facility at 8:45am and observed breakfast being made for the residents by the Licensee. The Licensee was the husband of the two Licensees, meaning the husband is still the cook when he is at the facility. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food. Continued on 9099-C

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Licensee does not provide planned activities for residents. It is alleged that the staff do not plan any activities for residents and do not take residents outside. The allegation states most residents sit at the table or sleep all day.

On 07/18/2023, the LPA conducted an inspection of the facility including the common areas, activities available, and outdoor areas of the facility. There is a dining room with a table capable of seating all six residents as well as a living room with a television and furniture for resident use. The backyard area has an indoor patio area/sun room equipped with furniture for resident use. The facility had activity supplies and equipment, including reading materials for the residents. At the time of the visit, LPA observed residents at the dining room table reading or playing crossword type games. LPA also observed a resident sitting in the backyard outdoor activity area. On 08/14/2023, LPA interviewed Staff members who indicated that activities for the residents included reading materials, games (crossword, word games, puzzles), and the television in the living room/common area.

Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of the report provided to the Administrator of the facility.