Complaint Investigation Report

On 06/07/2021 staff was interviewed at 2:21 PM. On 06/15/2021 LPA’s Rosales and Guzman-Chavez conducted a subsequent complaint visit at 10:04 AM toured the facility, interviewed staff at 11:52 AM, 12:09 PM, 12:53 PM, 1:34 PM, 1:44 PM, 2:13 PM, and 2:21 PM. LPA Rosales interviewed resident at 1:21 PM on 06/15/2021. On 06/17/2021 documentation received by LPA Rosales. On 08/02/2021 LPA Ascencio interview witness. On 08/24/2021 LPA Rosales interviewed staff at 9:22am. LPA Rosales reviewed documentation on 08/26/2021. LPA Rosales interviewed additional staff on 03/09/2022 at 9:22 AM, 9:37 AM. LPA Rosales made observations on another complaint visit on 03/10/2021 and interviewed staff at 2:00 PM and 2:28 PM relevant to this complaint. LPA De Leon was reassigned the complaint investigation

On the allegation: Staff failed to meet the resident needs. LPA’s interviews revealed it was known by 8/12 staff interviewed that R1 had behaviors. Interview with Administrator on 04/09/2021 stated that they have 1 Resident (R1) that has had some difficulty with behaviors to manage. Five staff reported R1 would yell and scream daily. Three staff reported R1 would bang or pound R1’s head on the wall. Two staff stated R1 throws things and slams doors. 2 staff stated R1’s medications were the problem either not getting them on time or being out of them. According to staff notes R1 did have prescriptions/PRN’s to manage behaviors and pain, but no medication records for R1 were provided to CCL for review. Staff notes indicate R1 would have behaviors and medications/PRN’s were given. And other times notes would indicate R1’s behavior with no PRN/medications given. Staff notes reviewed from 02/05/2021-04/28/2021 R1 had 76 entries of behaviors.

LPA De Leon reviewed facility incident report dated 11/17/2020 where R1 was taken to the ER on 11/17/2020 and a tooth abscess was noted. Facility did not provide any records of any dentist appointments from 11/2020-03/2021. S1 stated on 04/09/2021 that R1 had a dentist appointment on 04/05/2021 where R1 had deep cleaning, red gums and 1-2 teeth had an abscess. Administrator and 1 staff stated that they believe that the issues are related to dental pain.