complaint·September 28, 2023

Regarding the allegations: Staff failed to administer resident’s medication as prescribed. It was alleged that staff failed to properly assist residents with the self-administration of medication as prescribed. During a subsequent visit, LPAs Peraldi and Smith conducted a review of medication and medication documentation with the Administrators and observed the following: Resident #2’s (R2’s) Carbidopa-Levodopa (sp) per directions from physician, was to be administered four (4) times a day. However, the Medication Administration Record (MAR) confirmed that the Administrators were assisting with the self-administration of this medication three (3) times a day. The Administrators explained that R2 would refuse one (1) tablet of the medication and would only take the medication three (3) times a day. Based on the observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, and California Health and Safety Code the following deficiency were cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalty. Exit interview conducted. A copy of the report and appeal rights were provided. Regarding the allegations: Staff neglect resulting in resident's poor hygiene. Staff are not meeting residents’ incontinence needs. It was alleged that staff neglected Resident #1 (R1) hygiene and are not meeting R1’s incontinence needs. Interviews with staff revealed that residents, including R1 are bathed twice a week. Interviews with staff revealed that majority of residents wear diapers and that staff change resident’s diapers two (2) to three (3) times a day. Interview with Administrator revealed that R1 has a catheter and that R1 is on Home Health services. R1’s Home Health continues to monitor R1’s catheter and staff continue to tend to R1’s catheter within the scope of their care. During the physical plant tour on 8/17/2021, 08/25/2021 and 05/19/2023, residents appeared well groomed. The LPA’s did not smell any odors nor did residents indicate that staff are neglectful. Additionally, resident interviews did not reveal any issues with their incontinence needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to assist residents with diabetes care. It was alleged that staff failed to assist residents with diabetes care. During the interview with the Administrator, it was revealed that two (2) out of five (5) residents, including R1 require assistance with diabetes care. The Administrator stated that staff supervise and assist the two residents with their diabetes care, including blood sugar check. The Administrator stated that the two residents can inject the insulin pen on their own. Interviews with residents did not reveal any issues with staff neglect towards diabetes care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.