Complaint Investigation Report

Staff did not prevent a resident from smoking drugs inside the facility.

It was alleged that staff did not prevent a resident from smoking drugs inside the facility. To investigate, LPA conducted interviews with the Administrator, two current staff, and two (2) out of four (4) residents who were available. The Administrator denied the allegation and stated the facility maintains a strict no-drug policy and that staff supervision is provided at all times. The Administrator confirmed one resident death occurred in September 2022 while receiving hospice services for end-stage heart failure but denied any knowledge of drug use. Staff reported they were not employed at the facility in September 2022 and have never observed drug or alcohol use. Staff also confirmed that all resident rooms are monitored and that no residents currently require oxygen. Interview with two (2) out of four (4) residents stated that drugs are not used at the facility, substance use is prohibited, and staff maintain resident safety. Based on interviews and observations, there is insufficient evidence to support the allegation. This allegation is Unsubstantiated at this time.

Staff did not ensure that complete resident records were maintained at the facility.

It was alleged that staff did not maintain complete resident records. To investigate, LPA conducted interviews with the Administrator, two current staff, and two (2) out of four (4) residents who were available, and reviewed current resident files. The Administrator stated that all required documentation, including Admission Agreements, Physician’s Reports, and Appraisal/Needs and Services Plans, are maintained at the facility. The Administrator further stated that records older than three years are purged in accordance with Title 22 CCR . Staff confirmed that records are securely stored, accessible during emergencies, and complete.

Interview with two (2) out of four (4) residents confirmed that their medical and non-medical records are complete and accessible, and emergency personnel have never been unable to access records. During today's visit, LPA reviewed four (4) out of four (4) resident files and observed documentation was complete, organized, and maintained in compliance with regulatory requirements. Based on interviews and record review, there is insufficient evidence to support the allegation. This allegation is Unsubstantiated at this time.

Appeal rights explained and exit interview conducted.

Copy of this report signed and delivered.