Complaint Investigation Report

Interview conducted with staff, potential witnesses and records reviewed revealed the following: R1 moved into this facility on 05/23/2022. A care plan meeting was initiated by facility staff on or about 06/10/2022 and another in 8/2022. Service plans completed by facility staff dated 5/25/2022; 05/31/2022; 09/06/2022; 11/03/2022; 11/30/2022; 03/21/2023 and 05/31/2023 were observed on file and reviewed. The Service Care Plans did not have any signatures to confirm who completed the evaluation and who was present during the evaluations. Potential witness interviewed revealed that beginning 10/2022 – 9/14/2023 several care plan meetings were initiated by R1’s responsible person due to the increasing decline observed in R1’s condition. On or about 07/13/2023, former Executive Director Stephanie Funderburg reported to R1’s responsible person that they would conduct a 72-hour behavioral mapping to address any issues or concerns. No documentation or record of this was found on file. On or around 09/07/2023, R1 was evaluated by Silverado team, and it was agreed to have R1 tested for possible UTI due to the increasing behavioral changes observed. On 09/13/2023, R1 sustained a fall. Interviews conducted revealed that the facility did not follow through with sending labs out for UTI test results. R1's responsible person was informed by former Director of Health Services - Hope Langston that the lab never picked up the urine sample. No further action was taken by facility. On 09/14/2023, R1's responsible person contacted the physician and reported the increased decline observed and current symptoms; R1 was transferred to the nearest ER per physician orders; R1 was admitted to Los Robles Hospital on 09/14//2023 – series of tests were conducted. R1 tested positive for UTI and chest x-ray indicated pneumonia.

Based on the above gathered, there is sufficient evidence to support the allegations; therefore allegations “Resident care needs not met” and “Staff did not initiate meeting with resident's responsible person”; is deemed Substantiated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report and appeal rights provided.