Complaint·January 14, 2025

According to the memory care director, med techs shall ensure residents take their medication(s) before leaving their rooms unless there is a physician's order indicating that staff may leave the medication(s) with the residents. LPA interviewed resident #2 (R2) who stated that he/she gets medications from staff twice a day. In the morning, facility staff made sure he/she took the medication before leaving the room. However, in the evening, he/she took one pill in the presence of staff and staff would leave the the other pill by the bedside table for him/her to take it before bedtime as the medication causes dizziness. Based on the documents provided, both R1 and R2 did not have a physician's order to leave medications in their rooms unassisted. After the investigation, this allegation is deemed to be substantiated as facility staff did not assist residents with their medications. Regarding to the allegation of- resident sustained injuries during an witnessed fall due to neglect, the reporting party stated that R1 sustained bruising and broken skin from a fall and the shower mat was not placed on the floor by staff may have contributed to the fall. As part of the investigation, LPA interviewed the memory care director, the administrator and conducted observations. According to the administrator, the facility provides the non-skid shower mat to the residents and when a resident who is determined to be independent with their Activities of Daily Living including but not limiting to showers, it would be up to the individual resident to place the shower mat on the floor. The administrator acknowledged that the facility did not have a process to ensure the shower mats were placed on the floor for the residents who are independent with showers. According to the memory care director, the non-skid shower mats were supposed to be on the floor but staff would place them on the grab bars to dry after resident had showered. In regards to R1's fall, the administrator and the memory care director were aware of the fall and acknowledged that R1's responsible party requested the facility to place the shower mat on the floor at all times to prevent R1 from falling again and they stated that this was verbally communicated to facility staff. Based on the documents provided by R1's responsible party, LPA observed the shower mat was not placed on the floor on multiple days after R1's fall. During LPA's visit on 12/20/2024, LPA toured R1 and 9 other resident's rooms and LPA observed the non-skid mats were hanging on the grab bar in R1 and 5 other resident's shower rooms and the mats were all dried. After the investigation, this allegation is deemed to be substantiated. After R1's fall, the responsible party requested both verbally and in writing for the shower mat to be placed on the floor to prevent R1 from falling again and both the administrator and the memory care director acknowledged that it was endorsed to them. In addition, they stated the facility staff was in-serviced. However, it was observed by R1's responsible party and LPA that the shower mat was on the floor. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the memory care Director, and Appeal Rights provided.