complaint·December 5, 2021

Regarding the allegation: Medications are not being administered to residents per doctor’s orders It was alleged that residents were receiving medications outside of the prescribed window; for example, evening medications were administered closer to 10:00 p.m. or 11:00 p.m. To investigate, the LPA interviewed former management personnel whom worked in the Memory Care unit from May 2019 – March 2020. Whereas current staff were unable to corroborate the claims, interviews with former staff revealed that there was an incident in December 2019 where a resident had received medication at around 11:00 p.m. and as a result, a medication technician was fired for the error. During today’s visit, interviews revealed that on 11/28/2021, there was a medication error in the Memory Care Unit, where approximately twenty-eight (28) residents did not receive their 5:00 p.m. dosage of medication due to an alleged mis-communication. However, the medication logs were signed off, indicating that all residents had been assisted with receiving their medication. Records review demonstrated that the Executive Director reported this incident to LPA Kassandra Lopez on 12/01/2021. Interviews revealed that the residents’ primary care physician had been notified and residents were monitored for any adverse reactions. Based on the information obtained, there is sufficient evidence to support the claim that medications were not being administered to residents per doctor’s orders. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued. Regarding the allegation: Staff are not meeting the needs of the residents It was alleged that due to lack of care and supervision, residents were not being repositioned as needed and residents were falling and staff were unavailable to assist. Interviews confirmed that whereas staff do not keep repositioning logs, staff claimed that they reposition residents every two hours. In addition, staff stated that most residents are out of bed and are congregating in common spaces in the memory care unit. Staff claim there are two residents that stay in the room for an extended period of time but are regularly checked on. Additional interviews stated that in general, whereas the community is challenged with insufficient staffing and extended wait times, they still are able to meet the needs of the residents. Regarding falls, staff claim that residents are checked on frequently and regularly assessed if there is an un-witnessed fall. Staff also claim that for all falls, the community calls 911 to ensure there are no internal injuries or bleeding. Lastly, if a resident sustains an un-witnessed fall in their room, as residents are checked every two hours, residents could have fallen within that two-hour time period. Based on the information obtained, there is insufficient evidence to support the claim that staff are not meeting the needs of the residents. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff do not have proper supplies on hand for resident oxygen. It was alleged that the facility did not have distilled water for an oxygen tank. Initially, the LPA interviewed former management personnel whom worked in the Memory Care unit from May 2019 – March 2020. Information gathered from interviews were unable to corroborate the claim that supplies were unavailable. Interviews with current staff revealed that there is an assigned lead whom ensures that each resident room is equipped with ample supplies. The LPA toured several resident rooms in the Memory Care Unit and observed that each room had an individual supply of necessary items. Based on the information obtained, there is insufficient evidence to support the claim that staff do not have proper supplies on hand for resident oxygen. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: A manager is not always available for assistance. It was alleged that there was ‘rarely’ a manager available to assist as needed. Interviews and records review revealed that the Memory Care Unit had experienced staff turnover as it related to Memory Care Directors. However, staff claimed that for every shift, there was always a manager-on-duty or lead to refer to if there was an immediate need. Staff claimed that if the Memory Care unit was without a Director, there was either an assigned point person from the Corporate Office, staff could contact a medication technician, or the manager-on-duty would potentially be in the Assisted Living unit. Staff also shared that if the Memory Care Director was on site, they would sometimes assist with resident care, which could pull them off the floor. Whereas the community could improve the process for communicating the manager-on-duty for collateral agencies or visiting parties, there is insufficient evidence to support the claim that a manager is not always available for assistance. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.