Golden Manor Rest Home

Allegation investigated: Staff did not safeguard resident's personal items

On 10/23/2023 at 11:18 am Licensing Program Analyst (LPA) David España conducted unannounced initial 10-day visit to the facility and purpose of a complaint investigation of the allegations listed above were explained. Licensing Program Analyst (LPA) David España met Magdalena Romero, Day Manager and Administrator, Mark Ingber. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is clear of Covid-19 infection. Today’s complaint visit was conducted with Magdalena Romero, Day Manager and Administrator, Mark Ingber. The investigation consisted of following: Interviews and Record reviews. On 10/23/23, LPA obtained a copy of the current resident’s roster, staff roster, resident #1-#4 records. LPA España, toured the physical plant with Day Manager, interviewed R#1-R#4. (Evaluation Report continues LIC-0099-C) Unsubstantiated On 10/23/23, LPA obtained Resident and Staff rosters, R#1-R#4 file (ID/emergency information, Admission agreement, Physician's report, Needs and Services Plan, Mars). LPA obtained R#4 admission and discharge dates. LPA reviewed R#1-R#4 Preplacement appraisal information, Resident appraisal, Resident personal property and valuables files (June, July, August, September). LPA requested and received the following documents and files for R#1-#4: Resident Roster, Staff Schedule R#1-5 (Face sheet, Physician's Report, Admissions agreement, Pre-Appraisal, Needs and Services Plan.) Documents were received at the time of visit. On 10/23/23 from 11:18 am – 2:50 pm the Department interviewed (4) out of (66) residents (R#1-R#4) and (4) out of (66) reported no issues with personal items missing. On 10/23/23 from 11:18 am – 2:30 pm the Department interviewed (5) out of (21) staff (S#1-S#5) and (5) out of (21) reported no issues with personal items missing. Regarding Allegations: “Staff did not safeguard resident's personal items.” The investigation revealed the following: Regarding the allegation “Staff did not safeguard resident's personal items.” 4 out of 4 resident interviewed disagreed with the allegation and denied having any issues with safeguarding of their personal items. 5 out of 5 staff (S#1-S#5) denied the allegation, S#1-S#5 denied not providing safeguard resident's personal items. Interviews conducted with S#1-S#5, stated that the staff if asked to safeguard residents’ personal items they are to sign documentation to safeguard resident’s personal items. Interviews conducted with R#1-R#4 stated they have never had problems with staff and notices concerning personal items. In (R4)'s records show that, from 01/25/2007 to 07/11/2022, (R1) transitioned to the hospital from Golden Manor Rest Home. As a result of transition, (R1’s) medications did remain consistent per S#1. According to Medication Administration Records for (R#4), medications were taken daily, and no medications were missed or refused between 01/25/2007 to 07/11/2022. There were no non-prescribed medications issued by Golden Manor Rest Home per record review. Per record review #R4 has Scheophrenia Paranoid Disorganized per UCLA Family Health Center, 1920 Colorado Ave., Santa Monica, CA 90404. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. An exit interview was conducted, and a copy of the report was given to Administrator, Mark Ingber.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 11-AS-20231017151357

Allegation investigated: Staff did not administer resident's medication as prescribed. Resident was chemically restrained while in care. Staff not making sure resident is given enough water.

On 09/01/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit to the facility and was greeted by assistant administrator Magdalena Romero. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit by LPA Alvizar on 08/23/22. Subsequent visits by LPA Dabuet & Cloyd on 08/25/23 and LPA Dabuet on 09/01/23. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with residents, staff, and witnesses. Staff rosters, Resident rosters, Incident Reports, Physician's Reports, Appraisals/Needs and Services Plans, Medication Records, Progress Notes for resident #1 (R1), and other pertinent records associated with this complaint. A tour of the facility was conducted. (Evaluation Report continues LIC-0099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not administer resident's medication as prescribed. Resident was chemically restrained while in care. The details of the complaint alleged staff did not administer medication as prescribed to resident #1 (R1) under chemical restraint, as reported on the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. Specifically, the complaint focused on an incident that occurred on 07/18/22 at Golden Manor Rest Home. The Department reached out to the complainant for further comments but was not available. The (SOC 341) described resident #1 (R1) was admitted on 06/26/22 at Grand Park Convalescent Hospital (GPCH) where (R1) recovered from (R1’s) primary medical condition and was discharged on 07/18/22. On 07/18/22 (R1) reentered at Golden Manor Rest Home (GMRH). A few hours after being admitted back at Golden Manor Rest Home, (R1) collapsed and was taken to Daniel Freeman Hospital for weakness and was evaluated with dehydration. The complainant reported in the (SOC 341) (R1) was administered medication that was not prescribed and that (R1) had been treated for a bladder infection when (R1) returned on 07/18/22 to the Golden Manor Rest Home. In addition, it was reported on (SOC 341) that (R1) may have been over-sedated with medications on 0718/22. In (R1)'s medical records, from 06/20/22 to 10/22/22, (R1) transitioned between hospitals, skilled nursing homes, and Golden Manor Rest Home. As a result of these transitions, (R1’s) medications have remained consistent. According to Medication Administration Records for (R1), medications were taken daily, and no medications were missed or refused. There were no non-prescribed medications issued by (GPCH) or (GMRH). There were (13) of (15) medications prescribed by (R1’s) medical physician such as Lorazepam, Benztropine, Divalproex, Tamsulosin, and Fluphenazine all have side effects that may result in prostate and urinary tract issues according to the National Institute of Health (NIH). On 08/25/23 from 1:30 pm – 2:30 pm the Department interviewed (7) out of (65) residents (R2-R7) and (6) out (7) reported needing assistance with medication management and (6) of (7) have not encountered issues nor have been provided medications that are not prescribed by medical physician. (Evaluation Report continues LIC 9099-C) According to (SOC-341) it stated resident #1 (R1) on 07/18/23 was discharged from Grand Park Convalescent where (R1) was treated from 06/26/22 through 07/18/22. On 07/18/22, (R1) returned to Golden Manor Rest Home at 10:45 am. During lunch while sitting in the dinning room, (R1) collapsed and was hospitalized was noted to have been dehydrated by the hospital. Medical records for (R1), from period 06/20/22 through 10/22/22, (R1) transitioned in and out of hospitals, skilled nursing homes, and Golden Manor Rest Home. During these transitions, (R1’s) medications have remained the same. These prescribed medications such as Dilantin, Flomax, Keppra, and Restoril caused side effects of dehydration or dry mouth according to the National Institute of Health (NIH). In accordance with Medication Administration Records for (R1), medications were taken daily, and no medication was missed or refused. On 08/25/23 from 1:30 pm – 2:30 pm the Department interviewed (7) out of (65) residents (R2-R7) and (6) out (7) reported having no concerns or issues nor having experienced any symptoms of dry mouth or dehydration. (6) of (7) confirmed there is no shortage of liquids as it is provided with meals, snacks, and medication intakes. Liquids are also available upon request when requested. On 08/25/23 – 9:30 pm – 3:00 pm, the Department interviewed (4) out (19) staff (S1-S3) and reported residents are provided water with medications. A wide variety of juices, milk, coffee, and tea are available at all meals. There are liquid refreshments available during snacks or in the kitchen upon request. This source was verified by reviewing the facilities menu. During investigation visit on 09/01/23, the Department observed liquid refreshments were distributed to residents between 2:30pm - 3:30pm. (S1-S3) stated (R1) has never been limited or refused liquids. On 08/30/23 from 10:20 am to 10:30 am, the Department interviewed the responsible party witness (W1) to resident #1 (R1). (W1) who is a frequent visitor to (R1) reported not to have observed (R1) in a dehydrated state. (W1) was complimentary of staff for the care and supervision provided for (R1). (R1) was interviewed on 08/18/23, however (R1) is unable to communicate and carry on a conversation due to (R1's) health condition. A review of resident #1 (R1’s) Physician’s Report dated 01/30/2021, (R1) is capable of self-care and can feed self and follow instructions. Based on the information gathered, there is no evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) On 08/25/23 – 9:30 am – 3:00 pm, the Department interviewed (3) out (19) staff (S1-S3) and reported residents are only given prescription medication prescribed by a medical professional. (S1) stated (S1) is the only staff that prepares medication for residents. (S1) follows procedures, monitors residents who refuses to consume liquids or food, and will contact the physician. (S1) will contact the resident’s physician when changes occur with the resident due to medications. (S1) reported there had been no changes in (R1’s) medication orders when (R1) was readmitted back at (GMRH) on 07/18/22. On 07/18/22, (R1) only received one tablet of Lorazepam at noon before collapsing and being rushed to Daniel Freeman Hospital. A review of (R1’s) medication revealed (R1) is prescribed Lorazepam one tablet every 6 hours 7 am, 12 pm, and 8 pm, and Temazepam one capsule at bedtime. A mild to moderate level of sedation can be achieved with these medications, according to the National Institutes of Health (NIH). On 08/30/23 between 10:20 am to 10:30 am, the Department interviewed the responsible party witness (W1) to resident #1 (R1). (W1) who frequently engaged with (R1) reported no issues or immediate concerns with (R1’s) consumption of medications. (W1) was aware of the type of medications that had been prescribed and what their side effects may cause for long-term use. (W1) claimed that (R1) had a prostate operation and would be prone to bladder issues with the type of medications that (R1) was prescribed daily. (W1) stated being fond of the staff and how that facility operates and hopes (R1) to be accepted back once (R1) has recovered from the skilled nursing home. (R1) was interviewed on 08/18/23 however (R1) is unable to communicate and carry on a conversation due to (R1's) health condition. A review of resident #1 (R1’s) Physician’s Report dated 01/30/2021, (R1) required assistance taking medication. A review of (S1's) Med-Tech completed medication training courses. Based on the information gathered, there is no evidence to corroborate the allegations mentioned above. Allegation: Staff not making sure resident is given enough water. The details of the complaint alleged that resident #1 (R1) was not given enough water as reported in the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. It indicated that (R1) was dehydrated and did not have enough water. The Department reached out to the complainant for further comments and was not available. (Evaluation Report continues LIC 9099-C Based on information gathered, an inspection of the facility, observation, and interviews conducted, analysis of service records and medical records, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations is Unsubstantiated. No deficiencies were cited. An exit interview conducted with Magdelena Romero and a copy of the this report was provided.the state’s words, verbatim · CDSS document, Sep 1, 2023 · control 11-AS-20220817085015

Allegation investigated: Staff made inappropriate comments towards residents Staff are not providing adequate food service to residents Facility is not providing comfortable accomodations for residents Facility chairs are in disrepair Staff are not safeguarding residents personal belongings

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Magdalena Romero, Administrator The investigation consisted of following: Interviews and Record reviews. On 08/23/22, LPA Alvizar, obtained a copy of the current resident’s roster, staff roster, meal menu, resident #1 records. LPA Alvizar, toured the physical plant with assistant administrator, interviewed assistant administrator and R#1-R#6. On 07/13/23, LPA obtained Resident and Staff rosters, R#1 file (ID/emergency information, Admission agreement, Physician's report, Needs and Services Plan, Mars (June and July,) note of property given to R#1, Preplacement appraisal information, Resident appraisal, Resident personal property and valuables, and Menu for (July.) LPA toured the side patio and middle patio (metal chairs no cushions), office, dining room, kitchen, indoor chairs w/cushions throughout facility, A/C working properly at a comfortable 75 degrees, LPA also toured rooms# 4,12, 17, 36, 32, 49. Unsubstantiated Part of the 1st floor and 2nd floor have A/C, the entire facility has Heat. The 1st floor with A/C are dining room, kitchen, TV room and Lobby only. The rest of the 1st floor from the front office, room 1 - 21, there is no A/C, fans are provided upon request by residents. 2nd floor with A/C are rooms 45 - 50, and TV room only. The rest of the 2nd floor from room 22 - 44, there is no A/C, fans are provided upon request by residents. The resident's rooms have their own thermostat and can control their own heat. The facility building is an older building and cannot accommodate an entire A/C unit. LPA observed dinner being served. Dinner served was burrito, rice, salsa, fruit (mango) cup, and soup. LPA also observed staff’s inter-action with residents. Based on the LPA's Soto and Alvizar’s investigation, the investigation revealed the following. Allegation 1 – Staff made inappropriate comments towards residents. Interviews conducted with S#1 – S#6, communicated that they have never made bad comments toward any client and have not heard any other staff make bad comments to clients either. Interviews conducted with R#2 – R#6, communicated that staff has never been mean to them or said any inappropriate to them. LPA observed the staff inter-acting with clients during dinner, they were all friendly and helpful with the clients. The interviews and observations conducted did not concur with above allegation. Allegation 2 - Staff are not providing adequate food service to residents. Interviews conducted with S#1 – S#6, communicated that they sometimes eat at the facility and the food is good. They serve the clients good portions of food. If clients request 2nd’s they serve them more and offer them alternatives if they do not like what is being served. Interviews conducted with R#2 – R#6, communicated that they eat at the facility and the food is good. The staff does a good job with the food. LPA observed the food being served during dinner. The facility served, beef burrito, rice, fruit (mango), and soup. The food serve was of a good portion, enough to satisfy clients. The interviews and observations conducted did not concur with above allegation. Allegation 3 - Facility is not providing comfortable accommodations for residents. Interviews conducted with S#1 – S#6, communicated that the facility does provide comfortable accommodations, some of the clients have A/C and the clients that don’t have fans. They just to request a fan and they give it to them. In fact, a lot of the clients already have fans in their rooms. Interviews conducted with R#2 – R#6, communicated that the facility does provide comfortable accommodations. LPA observed some client’s rooms, and some had A/C and the rest of the rooms had fans in their rooms that the facility provided. Some clients did not need A/C or fans, they preferred to open their doors and windows and let the outside air cool them off. The clients had a nice breeze coming into their rooms. The interviews conducted did not concur with above allegation. Allegation 4 - Facility chairs are in disrepair. Interviews conducted with S#1 – S#6, communicated that the chairs are all in good repair, none of them are broken, the chairs are comfortable, and they have cushions for more comfort. Interviews conducted with R#2 – R#6, communicated that the chairs are not broken, and they are fine to sit. LPA observed the chairs used in the common areas, most of them had cushions, the chairs in the outside patios did not have cushion, but were still comfortable, LPA sat in the outside chairs, they were comfortable, and not broken. The interviews and observations conducted did not concur with above allegation. Allegation 5 - Staff are not safeguarding residents’ personal belongings. Interviews conducted with S#1 – S#6, communicated that they have never taken anything from any client, and they do not know about client’s clothes ripping, the clients haven’t complained to them about that. They have not stolen clients' belongings neither". Interviews conducted with R#2 – R#6, communicated that staff has never stolen or taken their belongings. LPA reviewed R#1 personal property and valuables, R#1 did not list or provide any property into the facility for safeguarding. The facility was not responsible for safeguard any belongings for R#1. The interviews conducted and records reviewed did not concur with above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Magdalena Romero, Administrator, and a hard copy of report was provided. This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 07/21/23.the state’s words, verbatim · CDSS document, Jul 21, 2023 · control 11-AS-20220815150323

Type of visit: Required - 1 Year

On 05/16/2023 Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced Required- 1 Year visit to Golden Manor Rest Home. Upon arrival at the facility, Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Corone conducted a risk assessment at the front entrance. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility submitted a mitigation plan report. The facility is licensed to serve 98 residents of which (42) may be non-ambulatory. There are currently no hospice waiver or bedridden residents at the facility. LPA met with Medical Technician Christina Revoloreo and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. Then later Administrator Mark Ingber and Assistant Administrator, Judith Montoya met LPA and joined the visit. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with COVID – 19 temperature logs. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored on site in a locked cabinet. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the front patio, courtyard or in the front living room, in addition to the resident’s bedroom. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility. The facility does not support residents with dementia and does not have a memory care unit. A vacant room was inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in common areas is clean, in good repair and also socially distanced. Please see LIC809C. There are no weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 118 degrees Fahrenheit in residents’ room and within regulation in the common area. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven (7)-day supply of non-perishable food. Knives and toxins were kept locked and separate. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to resident in care. The First Aid kit was available and inaccessible to residents. Several fire extinguishers were observed throughout the facility. Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Mark Ingber.the state’s words, verbatim · CDSS document, May 16, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 11/3/2021 at 08:32am, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Alvizar conducted a risk assessment at the front entrance. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility submitted a mitigation plan report. The facility is licensed for (56) ambulatory residents, of which (42) may be non-ambulatory. There are currently no hospice waiver or bedridden residents at the facility. LPA Alvizar met with Med Tech., Christina Revoloreo and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. Then later Administrator Mark Ingber and Assistant Administrator, Judith Montoya met LPA and joined the visit. LPA was properly equipped with Fit tested N-95. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with COVID – 19 temperature log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored onsite in a locked cabinet. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the front patio, courtyard or in the front living room, in addition to the resident’s bedroom. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility. The facility does not support residents with dementia and does not have a memory care unit. A vacant room was inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in common areas are clean, in good repair and also socially distanced. There are no weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 116.1 degrees Fahrenheit in residents’ room and within regulation in the common area. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven (7)-day supply of non-perishable food. Knives and toxins were kept locked and separate. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to resident in care. The First Aid kit was available and inaccessible to residents. Several fire extinguishers were observed throughout the facility. Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Assistant Administrator, Judith Montoya.the state’s words, verbatim · CDSS document, Nov 3, 2022

Allegation investigated: Facility staff withholding resident's money.

On 10/18/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Facility Day Manager Magdalena Romero who stated the facility is free of Covid-19 infection. The purpose of the visit was explained. The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Facility Day Manager Magdalena Romero. LPA Montoya interviewed twelve (12) residents and five (5 staff). LPA requested copies of Resident #1’s service records and other pertinent records. REPORT CONTINUED IN LIC 9099C Unsubstantiated Investigations Revealed: Allegation: Facility staff withholding resident's money. It is alleged that facility staff is withholding resident's money. LPA Montoya reviewed R1's service records and conducted interviews. Based on LPA’s review of Resident #1’s service records, R1 was admitted to the facility on 4/27/2019 and R1 is the responsible person for himself. S1 stated during interview that R1 is able to handle his own money and the facility does not handle R1's funds. LPA’s interview with Staff (S1-S5) and Residents (R1-R12) revealed they have not heard or observed any staff withholding resident’s money. R1 admitted no facility staff withheld his money. R1 stated he was confused. R1 rescinded his statement that a facility staff withheld his money. Based on interviews conducted, there is no sufficient evidence to corroborate the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. A telephonic exit interview was conducted with Facility Day Manager Magdalena Romero, and a hard copy was provided.the state’s words, verbatim · CDSS document, Oct 18, 2022 · control 11-AS-20221014092127

Allegation investigated: Resident self harmed while in care. Staff did not administer resident's medication as prescribed.

On 06/20/2022, Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to address the allegations listed above. LPA Agard met with Magdalena "Maggie" Romero, Asst. Admin and explained the purpose of this visit is to gather information for the complaint and deliver findings. On 06/20/2022, the investigation consisted of the following: LPA Agard conducted a tour of the facility grounds, interviewed staff, residents, witnesses, and reviewed records. LPA Agard requested the following documents, which were received at the time of first visit: 1) A copy of the staff roster, 2) a copy of the resident roster, 3) Needs and services plans for R1, 4) physician report for R1, 5) Medication Administration Record for facility, Re-habilitation, and Hospital, 6) Any incident reports. On 06/21/2022, LPA delivered findings. Cont. on 9099C Unsubstantiated The investigation revealed the following: Regarding the allegation: Resident self-harmed while in care. “It’s being alleged that a resident tried to kill themselves due to not receiving psych meds.” 4 out of 4 staff states that a resident tried to harm themselves but not due to an error in medication administration. On 06/20/2022 at 10:10am S1 states, “yes there was a resident that recently tried to harm themselves, but we didn’t know nothing. We didn’t see any signs. R1 cut both their wrist with a knife. They came downstairs and showed the staff their wrist. Residents are not allowed to bring those things in the facility. R1 is independent in the community, so we don’t know where they got the knife from. There was no history of suicide prior with this resident.” On 06/20/2022 at 10:22am S2 states, “I think it was Tuesday the 14th I saw R1 between 11:30am and 12pm. I asked them how they were feeling, and they reported feeling well. In the evening, R1 came for medication after being called several times. R1 showed their wrist to the staff. The staff called 911 and 911 came. We had no prior information on the resident being suicidal or self – injurious.” On 06/20/2022 at 10:39am, S3 states “R1 didn’t mention anything. They were always quiet, and never mentioned anything about wanting to commit suicide or kill themselves.” On 06/20/2022 at 3:04pm S4 states “the cuts were not bleeding when R1 showed me. It had been dried by the time they got downstairs and showed me. R1 cut horizontally across both wrists. I called 911 right away.” During interviews with the resident, 5 out of 6 could not confirm the allegation to be true. R1 was unavailable for an interview. All residents denied knowing R1 or any residents that recently tried to harm themselves. On 06/20/2022 at 11:01am R2 states, “Things are okay living here it’s better than the last place I was at before. I don’t know about any residents trying to harm themselves.” On 06/20/22 at 11:05am R3 states, “Oh I like it here. I like living here. There hasn’t been anyone recently that tried to harm themselves. Maybe a long time ago but nothing recent.” On 06/20/2022 at 11:16am R6 states, “I like living here. I’m happy. I don’t know about any residents trying to harm themselves. I don’t know R1.” Regarding the allegation: Staff did not administer resident's medication as prescribed. It’s being alleged that a resident was not getting their medication as prescribed. 4 out of 4 denied this allegation to be true. On 06/20/2022 at 10:10am S1 states, “yes, they have been receiving their medication as prescribed. No doses have been missed; they were on top of that. We are the ones that dispense the medication.” On 06/20/2022 at 10:22am S2 states, “R1 had been taking their medications as prescribed. No doses were missed. We are the ones dispensing meds. The resident was hospitalized on May 4th due to an issue with their diabetes. That Cont on 9099C could have been where the changes took place, but they did not take place with us. We did not make any changes to their medication, we just followed what was given to us from the hospital and rehabilitation center. R1 could be on the same medication but may just have a different name. I know that we did not make changes.” On 06/20/2022 at 10:39am, S3 states, “R1 has never missed medication. They are not in control of dispensing their medication.” During interviews with residents, 5 out of 6 couldn’t confirm this allegation to be true. R1 was not available for an interview. All residents state they receive their medication without issue. On 06/20/2022 at 11:01am R2 states, “they help me with my medication, and it is given to me properly without any issues.” On 06/20/22 at 11:05am R3 states, “they help me with my medication, and they are very good about it. They give it to me on time and don’t miss it. They call us to come every time.” On 06/20/2022 at 11:16am R6 states, “they give me medication in the morning and night. They do a good job. They never miss any medication. If you do not come, they will call you.” LPA reviewed the following facility and resident records: On or around 04/13/2022, R1 was appraised by Golden Manor Rest Home. The appraisal indicates resident to be independent in most activities of daily living with the exception of medication administration. A review of R1’s physician’s report does not indicate a history of suicidal ideation or self-injurious behavior. On or around 04/13/2022 R1 arrived at Golden Manor Rest Home with the medication administration records from Regency Manor, their previous facility. It included the missing psychotropic medication referred to by the reporting party. On or around 05/04/2022, per an incident report, R1 was transported to the hospital due to a hyperglycemic episode. On or around 05/09/2022, per order summary from Grand Park Convalescent, R1 was transferred to a rehabilitation facility. A review of the order summary report dated 05/25/2022 indicates a change in medication and the missing psychotropic medications observed on the records from Regency Manor. On or around 06/02/2022, per a copy of the current medication list, dated and signed by R1 indicates an additional change in medication. R1 returned to Golden Manor Rest Home with a current medication list that was being followed by the facility. The current medication administration records indicate the missing psychotropic medication referred to by the reporting party. Per a review of current medication administration records, there were no changes to R1’s medication by the current facility. LPA did not observe any dosages missed. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 21, 2022 · control 11-AS-20220616153521

Allegation investigated: Staff had an inappropriate sexual interaction with resident

On 02/16/2022 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA Agard met with Judith Muro, Personal Assistant and explained the purpose of this visit was to gather information regarding this complaint. The investigation consisted of the following: on 09/15/2021 Licensing Program Analyst (LPA) Troy Agard initiated a 24-hour complaint investigation for the allegation listed above. LPA Agard met with Christina Revolorio, Medical Technician, and the purpose of the visit was explained. LPA toured the physical plant. Due to time constraints, interviews were conducted at a later date. The following documents were requested: Current Resident Roster, Current Staff Roster, Staff roster from July 2021, requested documents were due to LPA by Wednesday, September 22nd, 2021. On 12/27/2021 interviews were conducted. On 2/16/2021 LPA delivered findings Cont. on 9099C Unsubstantiated Regarding the allegation: Staff had an inappropriate sexual interaction with resident. It’s being alleged, in mid July 2021, a former staff, came to do work in a residents’ room. The resident was cornered by staff, groped, and inappropriate acts were performed. The investigation revealed the following: During interviews with residents 4 out of 5 deny having inappropriate interactions with current and previous staff. R2 states, staff generally do not interact with him or touch him inappropriately. R3 states, the staff treat him well. “Yes, they do.” He denied any staff having inappropriate interactions with him. “No”. R5 denied the allegation stating, “Not at all”. R1 states they were touched in appropriately by a former staff. “S4 was standing in a way that indicated I was about to be molested. I have been in trouble before, so I knew what that look meant. I never reported it because I was afraid that something would come back to me. I didn’t call you people. Someone called for me.” During interviews with staff, the investigation revealed the following: S1-3 all denied the allegation to be true. S1 states, R1 keeps to themselves mostly and is under psychiatric care. R1 has a history of saying things that are not truths. R1 has in the past made false allegations against a Medical Technician. S1 states R1 alleged the staff had something against them because they’re transgender. S1states, S4 has worked at the facility for a few years. “They resigned voluntarily due to finding a better paying job.” S2 and S3 both states, not being made aware of any inappropriate sexual interaction between a resident and staff. “Honestly, with me, R1 doesn’t report anything. They never reported to me that anyone touched them inappropriately.” S4 was unavailable for an interview. During a review of the investigation conducted by Investigation Bureau (IB), the following was revealed: IB during an interview with R1, R1’s description of events was inconsistent, and the alleged perpetrator last name did not match. IB states, “During my interview with R1, the information provided change multiple times. When I asked follow-up questions, the information would change again. During my interview I found R1’s statement to not be credible.” During an interview with S4, IB states in summary S4 denied any involvement with R1 and was warned by staff to never go into R1’s room due to their history of false allegations against personnel. During an interview with S5, IB states in summary being told S4 no longer worked at the facility due to recently returning back to their previous employer. S5 states, “R1 has a history of making false allegations and no staff members are allowed in R1’s room.” Based on LPA’s observation, interviews conducted, record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 16, 2022 · control 11-AS-20210914155658

Allegation investigated: Staff did not provide resident transportation for medical services. Staff intimidates resident in care.

On 02/16/2022 Licensing Program Analyst (LPA) Troy Agard conducted an initial 10-day complaint investigation at the above facility to address the following allegations. LPA Agard met with Judith Muro, Personal Assistant and explained the purpose of this visit was to gather information regarding this complaint. The investigation consisted of the following: LPA toured the physical plant, conducted interviews with staff, and residents. The following documents were requested: current resident roster, current staff roster, and any discharge paperwork for hospitalizations. Requested documents are due to LPA by Wednesday, February 23, 2022. On 2/16/2021 LPA delivered findings. Cont. on 9099C Unsubstantiated Regarding the allegation: Staff did not provide resident transportation for medical services. It’s being alleged a resident was sent to the medical center under false pretense. A staff falsely reported to paramedics that a resident was complaining of chest pain due to lack of transportation services at the facility. The investigation revealed the following: During interviews with staff, 3 out of 3 denied the allegation to be true. S1 states, “we have a sports utility vehicle (SUV) that can take resident’s to medical appointments. We are usually really good about that. We recently had a resident (R1) who was sent to the hospital due to having really swollen legs. We had to call 911 because we sent him to urgent care a few times before and they didn’t do anything for him. R1 was sent back for the same issue. S2 states they had been informed by housekeeping on 02/07/2022 that R1 was complaining of chest pains, but it was observed that R1’s legs were really swollen. “I called 911 because I had previously sent him to urgent care like 3 other times and they did nothing for him. I was concerned because his legs were red with bubbles. He complained to S3 that he had a lot of pain in the chest. I was concerned so I called 911. S3 states, observing R1’s legs really swollen. “It was really really bad. I checked in the morning with their breakfast. R1 said I have chest pains. I asked if they were okay. They said no, I have chest pain but nothing about the legs. I told S2 so they could check R1.” During interviews with residents, 5 out of 6 denied the allegation to be true. R5 could not confirm the allegation to be true. “Yes, I go there, but I never use the facility’s transport. A lady from the Veterans Affairs (VA) comes to get me. R1-4 and 6 all deny having any issues with the facility transporting them to medical services. R1 states, “no I was not having chest pains. Someone made that up. I don’t know who made it up. I didn’t hear anybody say anything but when the paramedics arrived, they were after me for chest pains. S2 looked at my legs that were swollen and was upset. She called 911. My legs were retaining water and were swollen. They looked pretty bad.” Regarding the allegation: Staff intimidates resident in care. It’s being alleged a staff member intimidates a resident and is fearful of retaliation from this staff member. The investigation revealed the following: During interviews with staff, 3 out of 3 denied the allegation to be true. S1 states, “no, they’re actually very good with the residents and always concerned with their well-being. S2 states R1 wanted to go. I never forced them to go because Emergency Medical Services (EMS) would refuse to take them. S3 denies S2 ever tries to intimidate residents. During interviews with residents 4 out of 6 denied the allegation to be true. R2 states, “S2 is very nice to me I don’t have any problems with them.” R3 states, “S2 is incredible. Beyond nice to me and is incredibly competent. I don’t know what they would do without S2.” R4 states, “S2 is very good with me.” R1 states, “S2 Cont on 9099C may try, but I don’t think so. S2 is kind of aggressive.” R5 states, “S2 is so so, sometimes she is aggressive and intimidates me. S2 treats just about everyone in here like that. They yelled at me this morning for no apparent reason.” LPA reviewed copies of discharge paperwork which indicated resident R1 was sent for evaluation on 01/19/2022 for vitals check, on 01/25/2022 due to the swollen legs, on 02/04/2022 for heart failure symptoms and again on 02/07/2022. Based on LPA’s observation, interviews conducted, record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 16, 2022 · control 11-AS-20220208123725