complaint·December 19, 2024

Regarding the allegation: Staff do not ensure that resident is provided their medication(s) according to physician’s instructions. During today’s visit, between 10:28 a.m. and 11:15 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #1 (R1’s) Evening medications, Carbidopa-Levodopa 25-100 Tab, Acetaminophen 500 MG Cap, Quetiapine Fumarate 25 MG, and Memantine 10 MG Tab were not self-administered or given to the resident for 12/18/2024. Per record review and staff interview, notes or documentation from 12/18/2024 indicating that R1 refused the medication was entered on 12/19/2024. The ED stated that an in-service training will be conducted to remind staff to properly document medication refusals. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegation: Staff do not ensure that residents have an operable call button (pendant). Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that there are no issues with their call buttons. On 12/19/2024, the ED explained that the resident rooms now have a movement censor and the majority of residents have a pendant. The ED explained that staff periodically check if the pendants are functional. During the visit on 08/31/2023 and 12/19/2024, the LPA tested a random sample of residents’ pendants and observed them functioning properly. The information obtained during the investigation did not include evidence sufficient to corroborate the 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 deemed Unsubstantiated at this time. Regarding the allegation: Staff do not respond to requests for assistance in a timely manner. It was alleged that it takes up to two (2) hours for staff to respond to request for assistance. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed that staff respond to their request for assistance within 5-10 minutes. Resident interviews did not reveal any concerns regarding the staff response time. Interview with the ED conducted on 12/19/2024, revealed that staff aim to respond to request for assistance within 5 minutes. The information obtained during the investigation did not include evidence sufficient to corroborate the 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 deemed Unsubstantiated at this time. Regarding the allegation: Staff do not ensure that resident’s medication(s) are ordered in a timely manner. Resident interviews conducted on 08/31/2023 and 12/19/2024 revealed no concerns regarding staff ordering their medications. Staff interviews conducted 08/31/2023 and 12/19/2024 revealed that medications get ordered 7-10 days prior to the current medication cycle ending. 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 deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.