Complaint Investigation Report

The investigation revealed the following: Regarding allegation: Resident care needs are not being met. It is alleged resident was scheduled for surgery and physician's instructions were for resident to fast, staff did not pay attention to this issue, and fed resident delaying surgery. Interview with residents revealed 5 out of 11 residents stated to have their needs met by facility and staff. 5 out of 11 residents were unable to respond due to cognitive skills and 1 out of 11 residents stated not receive care from staff at the facility. Interviews with staff revealed 4 out of 6 staff stated they are familiar with the residents care plan and attempt to meet their needs. Assistant Administrator that there was a lack of communication with all kitchen staff which prevented server from retaining breakfast from resident the morning of surgery. Wellness director stated that the staff were instructed the night before to prepared the resident for surgery and retain food intake in the morning. However, caregiver and server did feed the resident in the morning. Document review revealed Flex notes had notes regarding surgery and instructions for R1. During internal investigation caregiver and server admitted to have not realize and fed R1 prior to the surgery. An employee warning notice forms were observed dated 10/19/21 for caregiver and server.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview conducted with Lori Lackey Assistant Administrator and a copy of the report, LIC 9099D, appeal rights were provided.