Complaint·November 7, 2024

LPA was unable to interview R2 during the investigation as R2 is no longer at the facility and LPA was unable to interview staff due to the staff involved no longer being employed at the facility. Based on interviews conducted & records reviewed, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with General Manager, Karen Nickolai and a copy is provided. Regarding the allegation, staff are not properly disposing of medication, according to the reporting party, the facility is not properly disposing expired medication and is not aware if residents are being administered expired medication by staff. During the investigation, LPA interviewed staff and observed the medication room. On 4/20/22, LPA observed a bin full of medication that needed to be destructed. According to staff interviewed, the last time the facility properly destroyed medication was on 2/15/22 because the facility has not had a nurse since March of 2022 and the nurse would be the one who would usually destruct the medications with the med-techs or the administrator as witness. In addition, according to the General Manager at the time, staff are supposed to destruct medications weekly however medications that needed to be destructed have not been destructed since 2/15/22 and LPA conducted the complaint visit on 4/20/22. On 11/7/24, LPA observed the medication room and observed a full box of medications that needs to be destructed on the floor. Regarding the allegation that med-tech room door is in disrepair, according to the reporting party, the Assisted Living med-tech room door is in disrepair, does not lock and is usually propped open, making medication accessible to residents in care. During the investigation, LPA interviewed the General Manager at the time and observed the Assisted living med-tech room. According to the General Manager at the time, in December of 2021, he/she was made aware that the med-tech room door was in disrepair and contacted third-party contractor, Vortex for a quote, however he/she did not send a confirmation to Vortex to repair the door. In addition, the General Manager at the time indicated, it was not till February 2022 when he/she officially sent an order to get the door repaired. Based on observations during the visit, LPA observed the med-tech room. LPA observed the top door hinge to be loose, a sign on the door stating disrepair and a nail in a ziplock bag from the missing nail on the door hinge. According to observations and interviews, the Med Tech room in assisted living is located inside the assisted living office, which is always locked. If the door is open, there is staff supervising the office and med-room. Continue to 9099C. Regarding the allegation, facility is not reporting incidents according to the reporting party, on 4/7/2022, resident 2 (R2) reported being hit by a care staff and doesn’t believe the General Manager at the time reported this incident to the state. LPA interviewed General Manager who indicated that there was an incident that occurred on 4/6/22 where a R2’s private caregiver reported to the Assisted Living Director at the time that R2 complained of a facility caregiver being abusive. The General Manager at the time admitted to not filing an SOC341 because she did not see signs of abuse or neglect after conducting the internal investigation. In addition, the General Manager at the time also admitted to not filing an incident report to CCLD for unknown reasons. The Department has conducted an investigation of the above allegations. Based on observations, staff interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations 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. Failure to correct said deficiencies may result in additional civil penalties. Report is reviewed with the General Manager and a copy is provided with appeal rights.