complaint·January 25, 2024

Regarding Allegation #1 : Staff did not provide adequate supervision resulting in residents wandering away from facility. This complaint alleged that R1 wandered away from the facility. LPA Calderon interviewed with A1. A1 stated that on 07/26/2022 R1 followed a guest out the front door of the facility at 1 pm. Staff searched for R1 when unable to locate inside the facility and then called 911. According to the police report #22-76564, R1 was found blocks away from the facility and was unharmed. LPA Calderon interviewed with S1-S3. 3 out of 3 staff admitted that R1 did wander away from the facility on 07/26/2022 and was recovered with no injuries in tack. facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 acknowledged that R1 did wander away from the facility due to the failure of staff supervision. On 11/02/2023 LPA Calderon reviewed the physician’s report (dated 03/07/2022) for R1. The report indicated R1 has a wandering behavior and requires observation and supervision. Regarding Allegation #2 : Resident has lost significant amount of weight while in care. This complaint alleged R1 lost a significant amount of weight while in care. LPA Calderon interviewed with A1. A1 stated that R1’s weight on 03/07/2022 was 136 lbs. and that R1 lost 15 lbs. A1 stated that staff did not keep track of R1’s weight, but that A1 had called R1 sister to advise that the facility would need a new doctor’s order regarding R1 weight. A1 stated there were no responses from the R1 family for the new doctor’s order. A1 claimed that the weight loss was not due to overmedication of quetiapine. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that most residents lose some weight until they get familiar with the facility and food and then usually gain weight. 3 out of 3 staff stated that R1 did lose some weight which is normal for a new resident. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 stated that new residents usually must get used to the food and lose some weight. R2-R3 reported that they also lost some weight at first but gained weight after getting used to the food being served. On 11/03/2022 reviewed food log notes (dated September 2022) for R1. The percentage of food consumed by R1 is logged in the log. It appears R1 ate 90% of his breakfast, 50% of his lunch, and 10% of his dinner. There were no logs of any changes to R1 weight. Based on interviews, observations, and supporting documents. The preponderance of evidence standard has been met; therefore, the allegation of Staff did not provide adequate supervision resulting in residents wandering away from the facility. Residents have lost a significant amount of weight while in care” is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref LIC9099D). A face-to-face meeting was conducted with Administrator Robin Aquino, and a hard copy was provided. Regarding Allegation #1 : Resident fell while in care resulting in injuries. This complaint alleged that R1 fell outside the facility and had bruising to R1’s face and a cut above the left eye. LPA Calderon interviewed with A1. A1 stated that there is no medical report or incident report regarding bruising to R1’s face or a cut above R1’s left eye. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that R1 was not injured while inside the facility. 3 out of 3 staff do not recall R1’s having bruises or a cut above R1’s left eye. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to R1's health conditions. R2-R3 states that R2-R3 has not seen R1 fall and that R2-R3 had not fallen or been injured from any incident. On 11/02/2023 LPA Calderon reviewed incident reports (dated 7/26/2022 to 11/09/2022). The incident report (dated 7/26/22) revealed that R1 left the facility and was found by the police safe and not injured. There is no incident report or medical report that states R1 was injured inside the facility. Regarding Allegation #2 : Staff is mismanaging residents’ medication. This complaint alleged staff are over-medicating R1 with quetiapine. LPA Calderon interviewed with A1. A1 stated that the staff did not overmedicate R1 with quetiapine and that the staff gave medication to R1 only as prescribed by doctors’ orders. A1 stated that if the staff had overmedicated R1 with quetiapine R1 would not have wandered away from the facility on 07/26/2022. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that R1 is given medications 2 times per day usually before mealtime. 3 out of 3 staff stated that the med-tech administers the medication and will document the Medication Administration Record (MAR) for R1. LPA Calderon conducted an interview with R1-R3 for this complaint. R1 was not able to answer any questions due to R1’s health condition and was unable to carry on a conversation. R2-R3 reported that staff gives medication 3 times per day and residents have noted that staff updates their records on what medication is given to a resident. On 11/02/2023 LPA Calderon reviewed the Centrally Stored Medication and Destruction record (dated 06/01/2022 to 10/10/2022) for R1. Quetiapine 25 mg, 1 tablet daily, 3 refills, there was no change in medication strength observed. Regarding Allegation #3 : Staff did not seek medical attention for residents in care. This complaint alleged staff did not seek medical attention for resident in care. LPA Calderon interviewed with A1. A1 stated that staff take care of residents’ medical needs. A1 stated that staff give medical attention to all residents and if residents need help there are staff to take care of residents’ needs. A1 stated that there are no medical or incident reports to suggest R1 was injured inside the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that all staff provided the best care and medical attention possible for each resident. 3 out of 3 staff claimed that if a resident is injured staff will seek medical attention right away. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2 expressed that R2 is independent, but that stuff is there if R2 requires medical attention. R3 claimed staff are attentive and if the call button for assistance is activated, the staff provides immediate attention. On 06/08/2023 LPA Calderon and S1 toured the facility. It was identified by LPA Calderon that staff members assisted various residents with medical problems, cleaned beds, and answered the call button whenever it was used. Regarding Allegation #4 : Facility did not notify residents responsible party of an accident in a timely manner. This complaint alleged facility did not notify residents responsible party of an accident in a timely manner. LPA Calderon interviewed with A1. A1 stated that there were no medical or incident reports noting any injuries to R1. A1 claimed that if R1 or any other resident was injured staff does call the resident family members to update the resident family on status. A1 claimed that R1 was not injured, and no call was made to authorized representatives. A1 indicated that when R1 wandered away from the facility on 07/26/2022, a staff and A1 called R1's family to update them on R1's status. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that S1-S3 are fully trained and are mandated reporters. As mandated reporters, any injuries must be reported timely to the administrator. This includes reporting to family representatives when an incident occurs. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to health condition. R2 expressed being independent and able to handle their own daily needs. R3 reported that family representatives are given status as required. On 11/02/2023 LPA Calderon reviewed incident reports for R1 dated 07/26/2022 to 11/09/2022. LPA Calderon observed staff reported the incident to the R1 family timely. Regarding Allegation #5 : Staff use zip ties to lock facility gate. This complaint alleged staff used zip ties to lock the facility’s front gate. LPA Calderon interviewed with A1. According to A1, residents from this facility live together without being segregated including some who are independent and some who require assistance with daily living activities due to memory loss. A1 stated that at no time has staff used any type of zip ties to secure the front door to the facility. A1 claimed that before R1 wandered from the facility on 07/26/2022 the front door had a normal lock. A1 stated that at no time did staff put a zip tie on the front door. A1 reported that since 07/26/2022 the facility’s front door has a security code that only staff knows to prevent residents with wandering behavior from leaving the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff denied ever using zip ties to secure the front door. 3 out of 3 staff reported that the front door currently has a security code to prevent residents with dementia from leaving without staff assistance. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health conditions. 2 out of 2 residents stated that they have never observed a zip tie used on the front door, but since 07/26/2022 maintenance changed the front door with a security passcode. 2 out of 2 residents claimed that some residents have dementia, and the security code prevents the resident with dementia from leaving without staff help. On 06//08/2023 LPA Calderon toured the facility and did not witness any zip ties but there is a security code staff must use to unlock the front door. . Regarding Allegation #6 : Staff took inappropriate photos of residents while in care. This complaint alleged staff took inappropriate photos of the resident while in care. LPA Calderon interviewed with A1. A1 reported that at no time would any staff member take photos of any resident for any reason without permission. LPA Calderon interviewed with S1-S3. 3 out of 3 staff claimed that they have never taken photos of R1 or any other resident without permission. 3 out of 3 staff stated that A1 has never ordered any of the staff to take any photos of R1. LPA Calderon interviewed with R1-R3. R1 could not answer any question due to health conditions. 2 out of 2 residents said that they had never seen staff take any photo or video of any resident being taken while at the facility. Regarding Allegation #7 : Residents denied visitation. This complaint alleged R1 family was denied visitation. LPA Calderon interviewed with A1. A1 reported that no staff member has ever been denied residents visitation rights to friends, guests, or family members for any reason. A1 claimed that there was a situation on 11/04/2022 where R1’s family was aggressive with staff and the staff had to call the Santa Monica Police Department. This information was verified with police report #22-76564. A1 claimed that the police came to the facility and asked R1’s family to leave the premises. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that S1-S3 have seen R1’s family visit many times. 3 out of 3 staff state that S1-S3 have never known any resident family or guest denied access to the facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 reported there have been no staff has ever denied them access to family or guest visits. R2-R3 have seen other residents’ family and friends visit over the years with no problems. On 11/03/2023 LPA Calderon reviewed the admission agreement (dated 04/07/2022) for R1. It is indicated under “Policies” concerning family visits, the facility is open to family and guests from “9 am to 7 pm every day”. A review of incident reports from 07/26/2022 to 11/09/2022 revealed there were issues between the facility and the R1 family, but no documentation that the R1 family was denied access to R1 or the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of Resident fell while in care resulting in injuries. Staff are mismanaging residents’ medication. Staff did not seek medical attention for resident in care. Facility did not notify resident's responsible party of an incident in a timely manner. Staff use zip ties to lock facility gate. Staff took inappropriate photos of residents while in care. Residents denied visitation. is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Robin Aquino (A1).