Complaint·June 13, 2024

and staff # 1-5 (S1-S5), LPA conducted a medication review for Residents #1-2 (R1-R2), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10). The investigation revealed the following: Allegation: Staff did not seek medical attention for resident. The details of the complaint allegation alleged that facility staff failed to obtain R1’s medication prescribed by Kaiser psychiatrist. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that med room staff were unable to administer R1’s medication as R1 is obtaining medication from Kaiser pharmacy and Kaiser pharmacy had not delivered the medication when requested by R1. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that when an outside pharmacy is used medication refills are ordered 7 days prior to the medication running out. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 8 of 10 residents denied the allegation above and reported receiving medication daily and have not run out of meds. 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA Villegas conducted (2) medication reviews and did not observe any discrepancies. Allegation: Facility staff failed to meet resident’s needs. It is being alleged that the facilities med room staff failed to monitor R1’s blood pressure. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that R1 does not have a doctor’s order for blood pressure checks. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that R1 does not have an order for blood pressure checks, however med room staff have been conducting blood pressure checks when it is requested by R1. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported med room staff conducted blood pressure checks daily, 3 of 10 residents interviewed reported not requiring blood pressure checks, 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA reviewed R1’s MAR for the months of April 2024 and May 2024 and did not observe a doctor’s orders for blood pressure checks. Based on interviews and records reviewed there is not enough evidence to support the allegation above. Although the allegation 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 is unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.