complaint·February 7, 2024

During the visit on 02/07/2024, Staff #8 (S8) unable to explain to LPA Brown why R1's MAR on 02/14/2023 to 02/16/2023 was blank, and provided LPA Brown R1's doctor order for the medication not dispensed to R1. In addition, LPA Brown reviewed R5 MAR and observed that R5 was not given a prescribed medication on 02/24/2023 to 03/01/2023 and another prescribed medication was not given to R5 on 02/19/2023 to 02/23/2023. During the visit on 02/07/2024, S8 confirmed to LPA Brown that R5 medications on 02/24/2023 to 03/01/2023 and 02/19/2023 to 02/23/2023 was not dispensed due to required pharmacy action. LPA Brown reviewed R1 and R5's Personal Services Plan (PSP) and LPA Brown observed that ordering and coordinating medications are included on R1 and R5's PSP in addition to assistance with taking medications and medication storage. Interview with Resident #6 (R6) indicated that staffs at the facility did not give R6 medication twice and reported that staffs at the facility occasionally mismanaged their medications. The second allegation indicates Staff are charging residents for services not rendered. LPA Brown determined that there was corroborating evidence that staff charged R1 for services not rendered. LPA Brown reviewed R1 Invoice from 02/2023 to 07/2023, and LPA Brown observed that the facility charged R1 for Escort/Mobility services not rendered or provided to R1 on 04/2023, 05/2023, and 06/2023. Staff #3 (S3) reported to LPA Brown that on incidents that a resident was charged of services not provided or rendered to the resident which happens, they immediately addressed the issue and they deduct the charged services that was not rendered or provided to the residents' account. During the visit on 02/07/2024, Staff #1 (S1) informed LPA Brown that residents are re-assess as needed and if there are any refunds needed, they give that to the residents as reflected in the residents' invoice the following month. S1 added that their facility nurses have full control of the assessment and if there are adjustments made to the residents' PSP but it's still their billing department that will adjust the amount in the residents monthly bill which takes time. Based on observation, interview and records review, the allegation of Staff are mismanaging residents medication (Allegation #1) and Staff are charging residents for services not rendered (Allegation #2) are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and Appeal Rights were discussed and provided to Executive Director Lisa To. Staff interviews revealed that they are recommending halo to the residents, but no incident happened that staffs are forcing residents to remove their bed rail. During the visit on 07/13/2023, R1 reported to LPA Brown that staffs at the facility are recommending halo as replacement for R1 and R5 bed rail but R1 did not state a staff forcing them to remove their bed rail. The second allegation indicates Residents room floor is not level. Resident interviews indicated that their room floors are level, and they are not aware of a resident stating that their room floor is not level. Staff interviews indicated that no resident at the facility reported that their room floor is not level. Staff interviews revealed that none of them observed any residents' room floor not level. The third allegation indicates Staff refused to take resident's blood pressure. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated staffs at the facility are taking their blood pressure regularly and no staffs at the facility refused to take their blood pressure when they request them to check or take their blood pressure. Staff interviews indicated that they never refused to take or check a residents' blood pressure. Staffs interviews revealed that Medical Technician staffs are taking or checking residents blood pressure every month and no incident happened at the facility that a staff refused to take or check a residents' blood pressure. Based on the evidence, the allegation that Staff are forcing residents to remove their bed rails (Allegation #1), Residents room floor is not level (Allegation #2), Staff refused to take resident's blood pressure (Allegation #3) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation 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 allegations are unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Lisa To.