complaint·March 19, 2024

Staff altered resident medication without consent. As stated in the aforementioned, Resident 1 and Resident 2 in question had their medications reviewed by the LPA. Resident 1 had an order in place to allow for her medications to be crushed. During the time of the visit, Resident 2 did not have an order in place to alter the resident’s medications. Medication for Resident 2 was altered without approval. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. One citation is issued for both allegations, as the allegations overlap with one another. Staff did not provide adequate supervision resulting in excessive falls . During the interview process, documents were obtained. Documents included Incident Reports for the month of December 2023. During the investigation, the administrator and several staff persons were interviewed. The residents were not interviewed due to their dementia status. The incident reports indicated that there were several falls by the residents. The administrator and several staff were asked if a process is in place when residents are at fall risk. It was reported that a procedure or a fall risk plan is not in place for individual residents. In addition, staff reported that they have not been trained on a specific “fall risk plan” for the individual residents that have ongoing falls. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed .