complaint·April 21, 2021

Resident #2 (R2) medication in room and not being centrally stored. During the medication review LPA was told that staff does not centrally store R2’s medications. During the review of R2’s physician report it stated R2 is unable to manage own medications. Based on LPA interview, observation, and record review this allegation is Substantiated at this time. Allegation: Responsible party of resident not notified of fall. There are concerns that facility staff did not notify R1’s responsible party about R1’s fall. To investigation this allegation LPA Richardson conducted a visit on 1/27/2020 and at 12 pm LPA RIchardson toured the facility and at 12:30 pm interviewed staff. On 10/1/2020, LPA Richardson conducted interview with R1's home health nurse and on 10/7/2020 at 10:15 am LPA interviewed R1’s relative. On today’s visit 4/21/21, at 10:00 am LPA conducted a facility tour and at 10:30 am, LPA conducted a medication review of all four residents who currently live at the facility. Based on interviews conducted, R1’s family was told by R1 about a fall (unknown date) when R1's relative arrived at the facility. After relative asking staff about the fall staff confirmed that R1 had fallen that day. Based on facility staff not communicating with R1’s family about the fall this allegation is Substantiated at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code Civil Penalties were assessed during this visit. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. The report was signed, however a copy of the signed report was emailed, along with the appeal rights On 1/27/21, when LPA conducted initial visit, the resident had moved out and taken medication and medication list and LPA was unable to review medications. On 4/21/21, LPA Richardson reviewed medications of all the residents currently living at the facility and based on review were given as described. Based on interview and record review there is insufficient evidence that R1 was not given medication as prescribed. This allegation is Unsubstantiated at this time. Allegation #2: Resident sustained a fall while in care. There are concerns that due to staff neglect that resident sustained falls. To investigation this allegation LPA Richardson conducted a visit on 1/27/2020 at 12 pm toured the facility and at 12:30 pm interview with staff. On 10/1/2020, LPA Richardson conducted interview with R1home health nurse and on 10/7/2020 at 10:15 LPA interviewed R1’s relative. Based on interviews conducted resident fell out of bed and sustained bruising. Facility knew that resident was a fall risk and had fallen before R1 moved into facility. Based on interviews conducted staff immediately came to check R1 and there is insufficient evidence that staff neglect contributed to resident fall. Therefore, this allegation is Unsubstantiated at this time. The report was signed, however a copy of the signed report was emailed.