complaint·April 26, 2021

The investigation revealed the following: Regarding allegation - Resident sustained injuries from multiple falls while medicated. It was alleged that Resident #1's (R1) medications taken during 2019 were causing resident to fall. According to the Administrator, Resident #1 (R1) had a couple of falls that were documented back in 2019. The falls were also reported to the R1's son and the physician. Based on the special incident reports, on 7/30/2019, R1 fell and was sent to the hospital and was brought back to facility without any injuries noted. On 8/2/2019, R1 had a fall at approximately 3:45am which R1 was sent to the hospital due to complaining of pain. The Emergency Room physician recommended that the resident be admitted for observation, but R1 and R1's son did not want the resident to be admitted and returned to the facility without any injuries or fractures. On the same day at 10:35am, R1 had another fall which resident sustained a hip fracture and was admitted to the hospital. 2 of the 3 staff LPA Chan interviewed recalled R1 having multiple falls but showed no signs of injuries and reported R1 was medication compliant majority of the time. Per Administrator, R1's doctor indicated the medications R1 was taking at that time were appropriate. Although resident had multiple falls, there were no evidence that R1 medications were causing the falls. LPA also did not see any signs of neglect from the facility. Regarding allegations - Facility is administering medication for resident without proper authorization and staff mishandling resident's medication . Administrator Tran indicated that she had spoken to R1's physician and questioned about the resident's medication since R1 was having multiple falls. The physician informed her that R1's medications were appropriate at that time. LPA Chan reviewed the physician's order and MAR log from July though October 2019 and medications appeared to match according to the physician's order. There were no indications that the Med Techs had mishandled R1's medications. 5 out of 6 residents that LPA Chan interviewed stated that the Med Tech brings their medications to them on time and takes them daily. The Medication Technicians also stated they would not distribute medication if not prescribed by the physician. Based on additional documents and interviews conducted, it does not change the previous unsubstantiated findings for these allegations rendered on the initial visit. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A telephonic exit interview was conducted with the Administrator Victoria Tran. A hard copy of this report was emailed for a signature and the appeal rights were also provided.