Complaint·May 10, 2022

Regarding the allegation of- facility did not assist resident with self-administration of medication as prescribed, the reporting party stated that the facility failed to assist Resident #1 (R1) with pain medication as ordered by the physician. According to Staff #3 (S3), R1 asked for pain medication in the middle of the night, and S3 did not feel comfortable of given it to R1 so S3 asked R1 to wait for S2 to give it in the morning as S2 was sleeping at the time. According to R1's hospital medical record, R1 has an order for Acetaminophen (Tylenol) every 6 hours as needed for pain. During an interview with S2, S2 stated that facility did not give R1 any pain medication during the time of R1's stay. Based on interviews and record review during the course of investigation, this allegation is substantiated as the facility did not give R1's pain medication as prescribed by the physician. Regarding to allegation of- staff did not regularly observe resident for change in condition, the complainant reported that the facility did not observe and check R1's blood sugar level as ordered by the physician which resulted R1's blood sugar rose to 282. According to Administrator, the facility did not conduct a pre-admission appraisal of R1 prior to R1's admission, therefore, the facility was not aware that R1 required blood sugar checks every 4 hours and then insulin injections accordingly until R1's responsible party informed the facility of such needs after R1's admission. In addition, the facility failed to conduct a pre-admission appraisal to ensure R1 is suitable for the facility. Furthermore, during the course of investigation, LPA observed injections and blood sugar finger stick checks for the resident who was not capable of performing it by themselves were administered by a facility staff who was not a skilled professional . These deficiencies will be cited on LIC809 and LIC809D. Based on R1's hospital documentation provided, R1 has Insulin Lispro Sliding scale 6 times a day with specific times and physician's order for insulin injection but the facility was not aware of these orders as the facility failed to conduct a pre-admission appraisal prior to R1's admission. 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. Report was discussed with administrator(over the phone), caregiver and Appeal Rights provided. A copy is provided. Regarding allegation of facility is malodorous- during the initial inspection, the staff provided a tour of the resident's rooms, living room, the big room, kitchen, dining room and the bathrooms. LPA observed facility was cleaned, tidy and odorless. According to the facility staff, they clean the facility every day and the residents also stated that the facility is cleaned and their rooms are being cleaned daily. Based on interviews and observation during the course of investigation, this allegation is deemed to be unsubstantiated. Regarding allegation of - facility did not ensure resident's medication was maintained at the facility, the Reporting Party stated that R1 brought pain medication to the facility upon admission but the facility could not find it during R1's discharge. LPA interviewed staff #2 (S2) and they denied the allegation and stated that upon R1's discharge, all the medication was taken by the Responsible Party who was present at the time. In addition, LPA observed the medication storage cabinet and did not find any medications with R1's name on it. Furthermore, LPA interviewed the other residents regarding to their experience of medication storage, and they stated they have not experienced their medication being missing. Based on interviews during the investigation, this allegation is deemed to be unsubstantiated. Regarding allegation of- Staff speaks inappropriately to resident, the Reporting Party stated that facility staff yelled at R1 when R1 asked for assistance. The facility staff denied the allegation and stated they never yelled at R1 and other residents. According to S3, R1 was ringing the bell very loudly for assistance during the night and S3 was very close to R1 so S3 asked R1 to not ring the bell so loudly as S3 did not want the sound of the bell to wake up other residents. As part of the investigation, LPA interviewed 2 others residents and both of them stated that the facility staff never yelled at them, they are attentive to their needs and respectful while speaking to them. Based on interviews during the investigation, this allegation is deemed to be unsubstantiated. Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED. Regarding allegation of- staff do not ensure that staff and residents are social distanced, the reporting party stated it was not staff who were not socially distanced from the resident, rather it was resident to resident as R1's bed was attached to resident #2 (R2)'s bed in the big room. Based on the above clarification information provided by the reporting party, this allegation is deemed to be unfounded. In addition, During the 10-day initial complaint visit, LPA observed R1 and R2's beds were positioned in a "L" shape and there were a table in between the 2 beds. Although the beds were not 6" apart, the facility did follow the head - to - toe orientation. Based on this investigation, this complaint allegations are determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis. This report is reviewed and discussed with administrator (over the phone) and lead caregiver. A copy is provided.