Complaint·July 7, 2023

The investigation revealed the following: Regarding allegation: Staff misplaced resident’s medication. It is alleged resident's medication (Norco) was misplaced. On 5/15/22 previous facility Administrator stated staff #2 (S2) had been given a warning as a result for leaving medication (Norco) on top of a file cabinet at the reception. S2 did not store the medication over night per facility’s policy, after it was delivered to the facility. Interviews with 6 staff revealed no concerns of medication being misplaced have been brought up by residents or other staff. Interviews with residents revealed, 10 out of 10 residents did not have concerns about medication being misplaced by staff. Documents review revealed an employee warning notice was given to staff #2 , who upon receiving medications (Norco) on 4/23/22 left the medication on top of filing cabinet and did not properly stored the medication. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Tittle 22, Division 6 and Chapter 8 is being cited. Exit interview was conducted with administrator and a copy of this report, LIC 809D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Resident fell while in care. It is alleged resident had a fall on the floor two to three months ago at 2:00am and was not assisted. Interviews with residents revealed, 9 out of 10 residents stated facility staff is quick to assist residents when sustained a fall and/or assist to prevent falls. 1 out of 10 residents stated staff take at least 45 minutes to respond when a resident needs assistance during a fall. Interviews with staff revealed, 6 out of 6 staff stated staff respond quickly when resident’s report a fall. Document review revealed, incident reports between February and May 2023 a total of 9 resident falls in which staff assisted with either helping resident during fall, body checks, and/or medication. Based on interviews conducted and document review, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not properly prepare food resulting in food poisoning and Staff does not provide adequate food service for resident. It is alleged the food at the facility are getting residents ill and food is either under cook or over cook. Interviews with residents revealed, 6 out of 10 residents interview stated to not have been sick due to food eaten at the facility and facility has not serve under cook or over cook meals. 4 out of 10 residents stated to have felt sick after consuming food at the facility. However, they did not go out to the hospital or reported their symptoms to staff. 2 out of the 3 residents stated food has either been under cook or over cook when served. Documents review revealed, there are no incident reports noting residents send out to the hospital due to food poisoning or related to food related illness. No physician’s notes for treating residents for food poisoning. Based on interviews conducted and document review, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff does not meet resident’s dietary needs. It is alleged resident’s food is not pureed completely. 8 out of 10 residents stated facility staff follow dietary needs for residents. 2 out of 10 residents stated dietary needs don’t seem to be followed by facility staff. Interviews with staff revealed, 6 staff stated to follow physician’s recommendation for dietary needs and when pureing food, the items are blended to the recommended consistency. (CONTINUED ON LIC 9099C) During facility’s tour on 5/18/22 LPAs observed puree meals prepared for at least 4 residents. Each puree meal was prepared according to the needs of the residents per staff. LPA observed some pureed meals consistency varied from broth like to thicker items. Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility phone is in disrepair. It is alleged resident waited 45 minutes prior to receiving assistance due to facility phone being in disrepair. Interviews with residents revealed 8 out of 10 residents stated the facility’s phone in their room works properly, connects to the main lobby, and receptionist answers their calls. 2 out of 10 residents stated the phone does not work and when they have attempted to contact staff in the main lobby, they waited up to 45 minutes. Interviews with 6 staff revealed each room has a telephone that directly connects with the main lobby. Receptionist responds calls as they come in. During facility’s tour LPA tested each residents’ phone that connects with the main lobby and each facility phone was in working condition. Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with administrator and a copy of this report was provided.