Complaint Investigation Report

157208915-1-7-2024-24-AS-MHON-CZEM9M-20240112082458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

This is an official report of an unannounced visit/investigation of a complaint received in our office on

10/03/2023 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20231003124747

Resident sustained multiple pressure injuries due to staff neglect

Resident sustained injury due to staff handling resident in a rough manner

Staff did not seek medical attention for resident

Staff did not allow hospice to come and provide care for resident

Staff are not providing adequate food service for resident

Staff left resident in soiled diapers for an extended period of time

Staff are not responding to resident's call button

Staff did not ensure resident had access to call button

On 01/03/2024, Licensing Program Analyst, (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA toured Resident R1's room and observed them sleeping in their bed, with call button and phone in hand. LPA reviewed facility staff response time in the call log records to be adequate and timely. LPA conducted interviews with family, facility staff and Hospice nurse. LPA reviewed R1's facility file, facility communication logs and Hospice care notes. R1 has been on Hospice care since 2022, and has had a continued decline in their health. Hospice records show R1 sleeps 18+ hours a day, has a decreasing appetite and eats 25 – 50% of meals per day, often refusing to eat. Documentation shows on multiple occasions, that R1 did not want to be touched and did not want the caregivers to change their briefs. LPA observed the facility to be in compliance with their assigned duties and responsibilities per the agreed Hospice care plan.

Based on the information received, the complaint allegations are Unfounded, meaning that the allegations are false, or are without reasonable basis, therefore, we have dismissed the complaint. Exit interview conducted with Administrator and a copy of this report was provided at the time of visit. No deficiencies cited.