Complaint Investigation Report

It was reported that "Staff prevented resident from having visitors", “Staff are not properly managing resident’s medication”, and “Resident records are not properly maintained” as it was alleged that facility staff denied a Home Health (HH) nurse access to visit Resident #1 (R1) and facility staff did not provide R1’s family with resident records. It was further reported that when R1’s family requested the medication for R1, staff stated that R1 was taken off that medication.

During the initial interviews with facility administrator and staff, all denied that R1 was ever a resident at the facility. Additionally, there was no documentation at the facility pertaining to R1. Moreover, Administrator and two staff members were shown photos of R1, but they stated they did not recognize the person in the photos. However, records obtained and reviewed during the course of the investigation reflected that Kaiser Permanente discharged R1 to Dependable Over Night Board & Care and R1 was admitted to the facility on 04/27/2023 . Facility contact person was listed as S1. Moreover, HH records reviewed reflected that HH contacted facility to schedule a visit on 07/15/2023 and spoke with S1 who informed HH nurse that the “…Pt is doing fine – taking meds, diseases under control, pt can eat and walk. If they need help they will let the pt’s sister know and MD…” It was further noted that “…Another agency attempted to go see the pt in the past and facility will not allow anyone…”

Moreover, during interview conducted with S1 on 12/20/2024, S1 recalled that R1 was indeed a resident at the facility and stated that S1 was confused when initially interviewed but remembered after. S1 admitted to not contacting the LPA to provide additional information. Additionally, S1 stated they spoke with HH nurse regarding R1 and notified that they were doing well and was able to walk. Staff stated that they were unaware why HH contacted them but that she would contact R1’s family, if warranted. Moreover, S1 stated they didn’t have any records for R1 at the time of the initial interview because they didn’t recall R1 however, later located the records. During today’s visit, LPA reviewed records for residents in care and did not observe any records onsite for R1. Administrator and S1 stated they will have to review what records they have for R1 in their archive and will send to LPA once they obtain it. Moreover, S1 stated that the family of R1 was responsible for obtaining the records from Kaiser and the facility was not responsible. S1 was not able to provide any information regarding R1’s medication or provide any documentation related to the medication.