Complaint Investigation Report

During the investigation process, and review of the resident’s (Resident 1) observation log, it was reported that on 01/15/25, 01/18/25 and 01/20/25, the resident was complaining of shoulder pain. Staff reported that they advised upper management of the resident’s pain, which was their protocol to have the resident sent out by emergency services. The management did not send the resident out until 01/21/25, which was six days later.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Facility staff did not report change in condition to authorized representative .

During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers.

During the investigation process, it was reported that the resident’s (Resident 1) responsible party was not notified of the initial complaint of the resident’s shoulder pain. It was reported that it was at least six days later before the responsible party was notified. The regulations state that when changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.