Complaint·May 27, 2022

Regarding the allegation, ‘Failure to contain records of resident's cash resources as specified,’ it is alleged that the facility failed to update clients’ P and I files since October 2021. On 03/16/22, interview(s) revealed that an outside agency credible witness visited the facility; and during the visit, the Administrator provided receipts, and advised that the facility would be updating the clients P and I’s as the facility fell behind. During the investigation, LPA Walker conducted a record review, and interview with the administrator. Record review revealed that three (3) out of four (4) client P and I files were up to date. Record review also revealed that client purchase receipts were accurate, and numbered. Interview with the Administrator revealed that facility client’s cash resources in the P and I book had not been updated for a few months. The administrator acknowledged the facility failed to follow regulation and keep clients P and I’s updated, as they ‘got busy, and fell behind.’ The Administrator also stated that the facility has since then implemented the suggested record keeping order from Regional Center since the last visit. Based on record review and interviews which were conducted, there is sufficient evidence to support the allegation ‘Failure to contain records of resident's cash resources as specified.’ Therefore, the above allegation is found to be Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued. Regarding the allegation, ‘Staff did not assist residents with self-administered medications as prescribed,’ it is alleged that facility clients’ medication count was off. It was also alleged that the facility staff did not have a sequence in which medication bubble packs were distributed. Therefore, there was concern that clients were not being assisted with the self-administration of medication as prescribed. On 03/16/22, interview(s) revealed that an outside agency credible witness visited the facility; and during the visit, three (3) out of four (4) client medications were reviewed. The interview(s) also revealed that during the medication review, there was no sequence in the bubble packs for the three (3) clients. Credible witness also noted the facility started backwards from the end of the month, and on the 20th for one month there was one (1) pill that was not punched. According to the credible witness, the explanation that was given was that the facility received a ‘new batch’ on the 27th. However, the credible witness could not confirm, as allegedly the medication count was still off. During the investigation, LPA Walker conducted interviews with the administrator, facility clients, staff, and conducted a medication audit. Interview with the administrator revealed that all clients are assisted with the self-administration of their medication on time. The administrator admitted to not having a set sequence in which the medication bubble packs were ‘popped.’ However, denied any medication being missed or staff not assisting clients with self-administered medications as prescribed. Interviews with facility staff revealed that no medication has been forgotten to be provided to clients. Interviews with facility clients revealed that staff have not forgotten to assist clients with self-administration of their medication. Interviews with facility clients also revealed that staff are ‘timely;’ and if staff are running behind due to cooking during lunch, clients remind them within ‘5 minutes.’ Medication audit conducted by LPA Walker along with Administrator Vahe Mkrtchian revealed that four (4) out of four (4) client medications were accurate, and accounted for. Based on record review, interviews with the administrator, facility staff, and clients, although there may have been times when client’s medication bubble packed were popped out of sequence. The facility staff have been retrained in following a sequence, and no medication was missing. Therefore, there is insufficient evidence to support the allegation ‘Staff did not assist residents with self-administered medications as prescribed.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was emailed.