complaint·March 11, 2025

Allegation: Staff handled resident in a rough manner resulting in an injury. It is alleged that on 5/30/2024, resident (R2) left the Memory Care Unit to the Assisted Living side of the facility and staff (S10) grabbed the resident's arm in a rough manner that caused injuries. According to information obtained, staff (S8) was terminated because of their actions. A total of 8 residents were interviewed. Two (2) out of 8 residents stated that former staff (S8) handled residents in a rough manner. A total of 7 staff were interviewed. Staff interviewed reported knowledge that former staff (S8) handled resident in a rough manner. Administrator Bautista stated staff (S8) was terminated due to excessive absences. Therefore, S8 was not interviewed. Staff interviews revealed that R2 was being transitioned into the memory care unit from the AL unit and often tried to elope by pushing hard the delayed egress doors. Staff (S8) grabbed the resident away from the door and as a result caused shoulder bruising. Staff interviewed stated R2 takes blood thinner medications that make the resident susceptible to bruising. In addition, according to information obtained on a different date S8 was observed being forceful when trying to get R2 in the bath. Based on interviews conducted on 5/30/2024, S8 used rough physical contact instead of redirection techniques. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not prevent a resident from falling out of a window. It is alleged that in July 2024 Memory Care Unit resident (R1) climbed out of a bedroom window due to lack of supervision. A total 7 staff were interviewed, of which all staff confirmed the incident. Based on record review and interviews conducted the findings indicate that on July 1, 2024, at approximately 6:30 PM cognitively impaired resident (R1) attempted to elope by going out of another resident's bedroom window in the 1 st floor Memory Care Unit. The resident fell and hit their head while climbing out the window. The resident sustained an open laceration to forehead and a dislocated shoulder. Memory Care Staff did a resident count and noticed the resident was missing and went looking for the resident. Resident (R1) was found outside the facility on the steps of the right side of the building. The resident was bleeding from the head and 911 was immediately called. According to staff interviews, on the date of the incident there were 3 staff in charge of supervising 22 Memory Care residents. One (1) staff was out to lunch, another staff staff was doing incontinence changes, and the 3rd staff was responsible for watching the residents that were in the dining/activity area. The staff watching the residents in the activity area had to leave to the restroom to assist a resident. The findings indicate that at that time six (6) residents in the Memory Care Unit were a fall risk and staff were not to leave them unsupervised. There is sufficient evidence to corroborate the allegation. Allegation: Staff altered residents’ medications. It was reported that med-tech staff (undisclosed name) removed names of residents off medication labels and put R3’s name on the medications to make it appear as if the facility had R3’s medications on site during LPAs review of medications pertaining to a different complaint investigation. The complaint alleges that during Summer 2024 some residents went two (2) months without receiving their medications due to pharmacy changes. A total of 7 staff were interviewed. Med-tech staff (S5) stated they have never altered medications and was unaware of the alleged incident. Med-tech staff interviews revealed that when the facility switched from Yorba Linda Pharmacy to Omni Care Pharmacy med-techs were having a hard time figuring things out in the medication room because some residents did not have medications during the transition. Staff requested an emergency supply of medications for some affected residents, but it took days for the facility to receive the medications. As a result, med-techs used house supply of some medications like, cough syrup and printed a QuickMar order and placed it on the medication, until the ordered medication was received. Since then, the facility has implemented a pharmacy medication consent waiver that allows med-techs to order the medications from the facility pharmacy "Omni Care" for residents whose families use a different pharmacy, so that when resident's medications are running low physician orders are obtained and families are notified that medications need to be refilled. The findings indicate facility med-techs did not order on time medications for some residents, and decided to alter physician orders by labeling medications improperly. Allegation: Staff did not administer medications to residents. Information received alleges that med-tech staff (S5) was logging in the electronic medication administration records software database that medications were administered but did not administer the medications. It is also alleged that med-tech staff were logging that medications were administered under employees that no longer worked at the facility. A total of 7 staff were interviewed. Staff (S5) denied the allegation. According to staff interviews, former med-tech staff (S9) reported to Administrator Bautista that "someone" was signing the Medication Administration Records (MARs) under another staff name that no longer worked at the facility. Administration staff did an investigation and discovered that staff (S9), whom reported the incident was the person that was signing off that meds were dispensed, under former staff (S11). Administration staff inventoried medications and completed a narcotic count and findings indicated that no narcotic medications were missing. Med-tech staff acknowledged that during the pharmacy change there medication errors. Based on Medication Administration Record (MAR) review, there is supportive evidence to corroborate the allegation. Allegation: Staff did not store files for residents in care. It is alleged that the facility did not have required resident file documents because a resident's file went missing from the medication room. A total of 7 staff were interviewed. Staff interviews indicated the facility maintains two (2) files, a business file and medical file. The medical files are kept in the medication room. Administration staff confirmed that during Summer 2024 one resident's file was misplaced/lost and unavailable for staff review. Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are cited according to Title 22. See LIC 9099D. Exit interview was conducted with Andrea Lopez. A copy of the report and appeal rights were provided. Allegation: Staff did not address water damage in the facility. It is alleged that the facility walls had water damage since Spring 2024 and as of August 2024 repairs had not been completed. Based on staff interviews and review of facility maintenance records the findings indicate there have been plumbing issues that are immediately addressed by in-house maintenance staff and contractors. There was water damage in the 3 rd floor ceiling hallway due to a roof leak. Maintenance staff removed the ceiling to prevent mold. It was left opened for approximately one week. Large fans were placed in the area to speed up the drying of the drywall. Licensee’s hired contractors in a timely manner to complete repairs. Residents interviewed stated repairs were completed promptly. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not ensure that residents rooms are kept clean and sanitary. It is alleged that there are two (2) residents whose rooms are unsanitary. It was reported that resident (R4) is a hoarder, has spoiled food in the room, and infestation of cockroaches. According to the report, there is another resident (R5) whose room is also not kept clean and sanitary. During LPA visits, the rooms reported to be dirty and not sanitary were observed being cleaned by housekeeping staff. Resident (R4’s) room was cluttered, but at the time of the visits floors and bathroom appeared to be regularly cleaned. The other rooms reported to be unsanitary were not observed dirty. All the rooms reported to have cleanliness issues are inhabited by resident's that like to discard food and other items on the floors. All residents interviewed stated housekeeping staff clean the rooms regularly and have no complaints about room and/or facility cleanliness. Based on observation, resident rooms appear to be regularly cleaned by housekeeping staff, and those reported to be unsanitary are due to resident’s hoarding behaviors, which are continuously addressed. All residents interviewed stated staff regularly clean resident rooms, and none reported any issues. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not keep facility free of insects. It is alleged that some resident rooms had an infestation of cockroaches. A total of 7 staff were interviewed. Staff reported that in the past there were several rooms that had cockroach infestation despite the rooms being cleaned regularly. A room on the 1st floor that was identified with the cockroach infestation was kept tidy and clean by the resident, but a crack in the baseboard was the entry point of the cockroaches from the room above on the 2nd floor. The 2nd floor rooms were being treated by extermination company. Records indicate the facility addressed pests’ issues by contracting regular pest control services. The facility is actively mitigating cockroach and insect reports. Residents interviews revealed the facility has ongoing pest control services in place. Proof of pest control invoices was provided showing the facility mitigates the issue when needed and also maintains prevention pest control services. There is insufficient evidence to corroborate the allegation. 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 . An exit interview was conducted and a copy of this report was discussed and provided to Business Office Manager Andrea Lopez.