complaint·January 11, 2024

In regards to the allegation "Staff left resident unsupervised after fall" it is alleged that R1 had a fall on 7/24/22 and staff did not stay with R1 until paramedics arrived. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Staff interviews state that staff are to assess to residents when there are any falls and based on the situation, call paramedics when necessary. Interviews show that it was staff S9 who assisted R1 when they fell and called the paramedics after assessing R1. LPA was unable to interview S9 to determine whether they had left R1 unsupervised. Based on observation, interviews and file review; although the allegation 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 allegations are unsubstantiated. In regards to the allegation "Facility is not adequately staffed" it is alleged that there are not enough staff at the facility to meet the residents needs. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews show that all residents are having their needs met in the facility. There is a phone application used by the facility caregivers that notes which residents in the facility need assistance based on their needs and services plan throughout each day. The staff will check off each task completed for each resident and no one is left unattended. Interviews state that medication aide staff and administration staff will assist when necessary to complete all tasks for the residents. Based on observation, interviews and file review; although the allegation 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 allegations are unsubstantiated. In regards to the allegation "Staff are not qualified to perform duties" is is alleged facility staff do not have basic required training's for their positions regarding medical issues. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews state that not all staff handle resident medications. That duty is assigned to trained medication aides and the Wellness Director. File review for medication aides show that staff have completed medication management training's as well as first aid /cpr trainings required of the position. All staff providing direct care to residents are also trained in resident wellness and recognizing signs of dementia . Based on observation, interviews and file review; although the allegation 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 allegations are unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff mismanaged residents medications" it is alleged that staff provided R1 the improper combination of medication. (8) of (8) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. LPA reviewed R1s medication records and did not observe errors. Interviews with staff state that doctors or psychiatrists will review resident medications and make the orders for any adjustments. The staff will collect the medication from the pharmacies and administer medications as prescribed to residents in care. LPA also observed doctor orders on file for medications observed. Based on observation, interviews and file review; although the allegation 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 allegations are unsubstantiated. Exit Interview conducted and a copy of this report was provided In regards to the allegation "Facility does not have a full time Activity Director" it is alleged the facility went months without a full time staff running the activities and social gathering. Interviews show that between the months of March 2022-July 2022 there was no full time activity director and the facility activities and social gatherings were being conducted by S2 whos position was not as a full time activity director. File review shows the S2 was given the title and hired as the full time Activities Coordinator on 7/5/2022 while the previous staff had left the facility in March 2022. This shows that as a facility, licensed for 50+ residents, failed to have a full-time staff who's responsibility is to organize, conduct and evaluate planned activities. Based on LPA interviews conducted and record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. See 9099D. Exit interview conducted and copy of the report with appeal rights was provided.