complaint·October 6, 2023

It was alleged that Staff did not ensure that resident’s bedrails were in place, resulting in resident sustaining a fall. Based on interview with resident (R1), he kept his bedrails up most of the time. Based on interview with home health nurse, when they would visit the resident, they observed R1 bedrails to be up. It was alleged that Staff dispensed incorrect medication to resident. Based on interviews with residents (R2, R3, R4 and R5), residents stated that they have had no issues with staff dispensing their medication incorrectly and/or not receiving their medication. R4 stated that facility staff knows what she needs and regulates her. Based on interview with R1, there was one incident where staff offered R1 the wrong medication, once R1 brought it to staff attention, they dispensed the correct medication to him. R1 stated that other than this one incident, all other medication has been dispensed with no issues. It was alleged that Staff did not ensure that resident took the medication that was dispensed to them. Based on interview with R1 home health nurse, they once observed medication on the floor in the resident’s room. Home health nurse asked resident about it and was informed that the medication was dropped by accident and staff gave them another pill to take. Based on interview with R1, there has been no issues with them not talking their medications. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided. This is an amended report from 10/06/2023. It was alleged that Staff did not respond to resident’s calls for help after resident sustained a fall Based on interview with (R1), R1 went about 6-8 hours before they were helped back into bed. R1 was unable to reach their call button but verbally called out for help. Live-in Staff were unable to hear R1's verbal call. Once R1 was assisted back to bed he was okay. R1 stated they did not sustain any injuries. Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) is being cited on the attached LIC 9099D . Exit interview conducted. A copy of this report and appeal rights provided.