complaint·June 24, 2022

LPA reviewed the Medication List and determined that the medication that was missed was supposed to be administered on certain days including the day of April 17, 2022. Facility failed to administer the medication based off of physician’s instructions (See LIC 9099D) . During the Document Review of the Medication Assessment Record (MAR), LPA observed the medication documentation was not accurate due to the facility staff missing a medication pass and not properly documenting the medication that was missed on April 17, 2022. In addition, the staff member that missed the medication pass did not communicate to upper level management regarding the missed medication for that day nor document in the MAR the missed medication (See LIC 9099D) . Complaint alleges that Resident's care plan was not adhered to when facility failed to respond to Call Bell in a timely manner. During the course of the investigation, LPA reviewed facility records and learned that on April 17, 2022 the resident call bell was not responded to when pressed. The resident had to wait 1 hour and 40 minutes before a staff member responded to that call bell (See LIC 9099D) . Complaint alleges that there are unqualified staff at the facility. During the course of the investigation, LPA conducted interviews and reviewed facility records and learned that 9 staff members have not had the required training hours as specified in regulation (See LIC 9099D) . The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Resident Relations Director, Linda Nguyen . Complaint alleges Facility is in disrepair resulting in resident's room temperature not being maintained according to regulation, Facility does not have operable keys for resident's rooms and facility does not have enough staffing to meet resident's needs. During the course of the investigation, LPA toured the facility on June 17, 2022, May 26, 2022 and May 4, 2022 and was granted access into the rooms. Facility staff members had operable keys to residents rooms and all parts of the facility. LPA did observe that the temperature of the facility was at a comfortable temperature with exits free from obstruction. LPA toured a sample of residents rooms that had a comfortable temperature. Residents appeared to be content and happy with the temperature in the facility. During the tours of the facilities on said dates, LPA observed the facility to be adequately staffed. In addition, during a document review, LPA found the LIC 500 to be appropriate during the investigation. Complaint alleges Resident's medications were not managed properly. During the course of the investigation, LPA could not prove or disprove that the medications were not managed properly or that there was missing medication. A finding that the complaint allegations of, Resident(s) personal rights were violated, Facility is in disrepair resulting in resident's room temperature not being maintained according to regulation, Resident's medications were not managed properly, Facility does not have operable keys for resident's rooms, Not enough staffing to meet resident's needs. are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Resident Relations Director, Linda Nguyen.