Complaint·September 20, 2023

A review of R2’s MARs dated 06/23/22-07/22/22 indicated eleven (11) different medications were not given to include nineteen (19) missed doses. Also, R2’s Insulin was not given for the entire month as prescribed for morning or bedtime. Facility staff interviews revealed the medication technicians were not correctly documenting the MARs. Facility staff also stated R2 administered their own insulin but was unable to state why the MAR did not reflect the insulin was provided. A review of R2’s MARs reflected medications were not given as prescribed. It was also alleged that R1 had accessibility to items that pose a danger. It was reported R1 had a knife and fork under their pillow and loose medications in their drawer. Administrator’s interview revealed a knife and fork were confiscated from R1’s drawer. However, there were no medications observed in the drawer. It was unknown how R1 obtained the knife and fork. Once made aware of the items the administrator had the items immediately removed. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Business Office Assistant, Ruth Granda whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2] R1’s Resident Appraisal dated 03/23/20 indicated R1 used a walker, needed assistance with bathing, grooming, toileting, medication management, and night supervision. R1’s Functional Capability Assessment dated 03/23/20 indicated R1 used a walker and needed help with bathing, dressing, and toileting. Staff interviews revealed R1 was able to toilet independently and R1’s family bought R1 depends as a preventative measure. Outside source interviews confirmed R1 was able to toilet independently. Additional outside source interviews revealed there were no concerns for the broken wrist as R1 had an accidental fall, while independently using the restroom. It was also alleged staff did not provide incontinent care and R1 sustained a rash. R1’s records indicated R1 required assistance with incontinence care. However, interviews revealed R1 was able and did toilet independently. A review of R1’s medical records for 07/03/21 reflected R1’s skin was negative for rash. In addition, the medical records did not identify depends/diapers being worn or skin breakdown due to incontinence. Outside source and staff interviews confirmed R1 was able to toilet independently. It was also alleged the licensee did not assist or arrange medical care for R1 for approximately one (1) year. Outside source interviews stated there was an assumption R1 did not receive medical treatment due to being in the locked memory care unit. However, all residents have the right to medical care regardless of location within the facility. R1’s spouse was the Durable Power of Attorney (DPOA) and assisted R1 with their medical appointments. Outside source interviews revealed the DPOA had complete control and did not allow R1’s family members to be involved with the medical care. The administrator’s interview revealed R1 received appropriate medical care, which was monitored by the DPOA. The DPOA made R1’s appointments and took R1 to them. R1 also had a lot of virtual medical visits due to Covid-19. R1 had their own cell phone in their room and would contact their physician on their own. R1 knew how to call in their own medication refills and discuss them with their physician. A review of R1’s records indicated R1 had multiple scheduled medical appointments to include visit documentation. Lastly, it was alleged the staff did not safeguard R1’s personal items regarding fans. Client/Resident Personal Property and Valuables form was completed for R1. There were multiple items listed. However, there were no fans indicated on the form. The administrator stated the facility provided fans to residents during the hot weather and was not aware of any missing fans. During the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Business Office Assistant, Ruth Granda whose signature below confirms receipt of these rights.