complaint·June 16, 2021

The investigation revealed the following: Staff inappropriately dispense resident's medications It was alleged that medications were not given according to physician's orders and that night time medications were left on the night stand for R1 to take, resulting in missed medications. On 5/25/21, LPA observed that medications were locked and centrally stored. During interviews, the administrator and staff stated that medications are locked and they give medications according to physician's orders. The residents interviewed stated that the staff give them their medicine. However, during the visit on 5/25/21, LPA reviewed medications and MAR logs for 3 residents and observed medication errors. For R5, medications were incorrectly marked off on the MAR but still in the bubble pack. For R2, there was nothing marked on MAR for the month of May even though the medications were taken from the bubble pack. For R4, night time/PM medications were marked as taken on 5/25/21 even though it was daytime when LPA reviewed the medications. The MAR log for R1 was reviewed and it showed days that were not marked off, indicating missed medication. Facility did not provide POA a copy of admission agreement It was alleged that R1's responsible party did not receive a copy of the facility's admissions agreement. LPA reviewed a copy of the admissions agreement. During interviews, F3 stated that he asked the administrator for a copy of the admissions agreement on multiple occasions but was never provided with one. The administrator stated that she did not provide R1's responsible party with a copy of the signed admissions agreement because she was unaware that she was required to provide a copy. Based upon observation, record review, and interviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted with the administrator, and copy of this report and appeal rights were provided via email. The investigation revealed the following: Facility does not have sufficient staff to meet resident's needs During interviews, the administrator and staff stated that there are 2 staff per shift daily, including overnight. Staff denied that there are any staffing shortages. F2 stated that there were 2 staff when he visited the facility, and F3 stated that R1 told him there were 2 staff during the day and 1 at night. Residents interviewed stated that there are enough staff to assist them. During the visit on 5/25/21, LPA Spencer observed that there were two caregivers and the administrator present. A review of the staff roster shows that there are 2 staff per shift, plus 2 additional on-call staff. Resident was not supplied with appropriate bedding During the visit on 5/25/21, LPA Spencer observed that all residents had clean sheets on their bed, and the linen closet had back-up supply of sheets. During interview, the administrator stated that residents have their sheets cleaned daily, and there are back-up sheet sets available for each resident. The administrator stated that when staff clean the sheets, they put a replacement set on the bed right away. S1-S5 stated that sheets are cleaned everyday and a replacement set is put on the bed right away. Residents interviewed stated that they have clean sheets and R5 stated that sheets are cleaned weekly. F3 stated that they had heard that the facility did not keep clean sheets on the bed, while F2 did not remember. Staff did not notify POA of resident's fall It was alleged that R1 had a fall in December 2020 and that R1's responsible party was not notified of the fall. A review of R1's face sheet shows that F3 is listed as the responsible party. In an interview, F3 stated that he was not sure if he was notified of a fall, while F2 stated that he had heard about the fall. The administrator stated that the F3 was notified as well as R1's physician. All staff stated that if there is a fall, they notify the administrator who then notifies the family and physician. R5 stated that when she had a fall, her daughter was notified, while other residents stated they were unsure. A review of R1's needs and services plan reveals that the fall occurred on December 19, 2020 and it was documented that the nurse and responsible party was notified. Facility allowed visitors inside the facility without requiring PPE During the visit on 5/25/21, LPA Spencer observed signage at the facility regarding mask requirements. A review of the facility's COVID-19 policy shows that visitors are screened, must wear a mask, and use hand-sanitizer upon entry. The administrator stated that visitors are required to wear masks, but stated that F1 visited on several occasions and refused to follow the facility's rules regarding masks. F2 and F3 stated that they were required to wear masks when they visited the facility. All staff interviewed stated that visitors are required to wear masks. R5 did not think visitors were required to wear masks, and R2-R3 was unaware if visitors were required to wear masks. ***See LIC9099C for continuation. Staff restrict resident in bed During interviews, F2 and F3 stated that they heard that residents are forced to stay in bed all day. The administrator and staff denied that residents are restricted to stay in bed and can be assisted by staff to get exercise daily. The administrator stated that there is 1 bedridden resident, and the rest are non-ambulatory. On 5/25/21, LPA Spencer observed that a resident was walking around with her walker and was assisted by staff when she requested to get out of bed. R2 and R5 stated that they prefer to stay in their room and do not often leave the bed due to preference, while R3 stated that she is always in bed and doesn't like it because it hurts her feet. LPA Spencer observed R3 asking staff to assist her to get out of bed and staff assisted the resident. Based on observation, interviews and record reviews, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. An exit interview was conducted and a copy of the report was provided to administrator via email.