complaint·January 16, 2025

During a visit conducted on 1/16/2025, LPA conducted a medication count for residents R2 and R4, comparing the residents' Centrally Stored Medication Form (CSM) with medications centrally stored for the residents. LPA observed one (1) medication for R2 that was off count in relation to what was documented. Medication that was off count was under the amount documented. There were no documentation to account for medication that was under the amount documented. LPA observed two (2) medications for R4 that were off count in relation to what was documented. One (1) medication that was off count was over the amount documented and one (1) medication that was off count was under the amount documented, There were no documentation to account for medications that were off count. Based on medication count, LPA's observation, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Interview with Administrator, Mark Graham, indicated that resident (R1) was able to administer their own injectable medications. Interview with staff member (S2) indicated that they were responsible for making sure R1 received the right amount of their injectable medication, but R1 self administered their own injectable medication. LPA observed a Physician's Report LIC 602A for R1 dated 10/01/2024, which indicated that R1 was able to administered their own injectable medication. Interviews with resident R2, R3, and R4 indicated that they had no concerns regarding medication administration at the facility. Allegation: Staff are not meeting residents' hygiene needs Interviews with staff members S1, S2, and Administrator indicated that the residents receive sufficient care with bathing, grooming, and hygiene. Interviews with R2, R3, and R4 indicated that they had no concerns regarding facility staff assisting with bathing, grooming, and hygiene. LPA observed records documented by S2 showing multiple dates in which R1 refused showers. Allegation: Staff are not ensuring resident was seen by a doctor Interview with Administrator indicated that R1 had a doctor assigned to them outside of the area and was working on finding a local doctor. Administrator stated that R1 was resistant when facility attempted to assist R1 with locating medical assistance in the area. LPA observed After Visit Summaries dated 11/16/2024 and 12/06/2024 indicating that R1 was seen by a medical professional for different conditions. Interviews with R2, R3 and R4 indicated that they had no concerns regarding being seen by a doctor. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Licensee. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.