complaint·January 20, 2023

Continued from LIC9099... However, R1 has not schedule a time with facility chef to go over the recommendations. Based on records review and interviews, LPA did not obtain enough information to support the allegation of facility is not following specialized diets. A finding that the complaint allegation facility is not following specialized diets is unsubstantiated meaning that 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 allegation is UNSUBSTANTIATED. Regarding the allegation of Facility does not ensure there is a designated substitute on duty at all times qualified to act in the absence of the administrator. According to Reporting Party, on October 10, 2022 around 10pm, staff (S1 and S2) came to conduct round checks to resident’s rooms due to call lights were out and staff were attempting to contact Administrator but their phone went directly to voicemail and emails sent alerting about the issue were not answered. Staff was not able to reset the system, so it wasn’t reset until the following morning, but the main concern is that there is no designated substitute to address any emergencies. On 10/20/22 and 12/2/22 LPA conducted confidential interviews with facility staff (S1, S2, S3, S4, S5, S6 and S7) confirmed the incident that occurred the night of October 10, 2022 when the computer was black and pulled a “error message” so they contacted Executive Director who instruct them to conduct more frequent round checks to residents in care. However, they were not able to resolve the incident until next morning when morning staff were able to fix the issue with the computer just unplugging the cord and plugging it back again. Also, they told LPA that in case of emergencies they contact Health Services Director or Executive Director who are very responsive during nights and weekends. The facility provided LIC308 Designation of facility responsibility indicating that Administrator Mariele Soriano has designated Executive Director as their authorized representative in their absence and LIC500 Personnel Report indicates that Executive Director will be available 24/7. A finding that the complaint allegation facility does not ensure there is a designated substitute on duty at all times qualified to act in the absence of the administrator is unsubstantiated meaning that 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 allegation is UNSUBSTANTIATED. Continues on LIC9099C... Continued from LIC9099C... Regarding Facility does not have an effective emergency plan. It is alleged that the facility only has one generator, and when the power went out, the power did not reach the second floor so CPAP machines didn’t work, after they inquired about it with Executive Director, they were told that there are emergency plugs that work off the generator, but the plug is down the hall and the staff don't know where the extension cords were located. Based on records review provided by the facility, the facility emergency disaster plan LIC610E along with ongoing monthly disaster preparedness meetings conducted with all staff, residents and their family including detailed information about who to contact, yellow door tags use, emergency access, color coded, evacuation locations, protocol, timing, mass communication utilizing One Call Now system, transportation, resident go bags, etc. During confidential interviews with staff, it was confirmed that they have been receiving ongoing disaster drill trainings and were able to identify where the emergency supplies including emergency plug location in the facility. Also, the facility provided electronic communications dated 6/6/22, 6/24/22 and 7/12/22 addressing resident’s concerns regarding emergency situations. A finding that the complaint allegation facility does not have an effective emergency plan is unsubstantiated meaning that 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 allegation is UNSUBSTANTIATED. It was alleged that facility did not give resident medication according to Physician’s order. Per Reporting Party, the night of October 10, 2022 while the computer system was down, they heard the following day at breakfast from a staff that a Med-Tech staff forgot to give a male resident their medication. However, they did not want to give the resident's name. Based on records review provided by the facility. LPA obtained and reviewed Medication Administration Record (MAR) for the period 10/01/22-11/30/22 for all male residents for the assisted living area. Based on records review, the MAR did not reveal that any resident has missed their medication while the computer system outage. During confidential interviews with facility staff this information was confirmed. A finding that the complaint allegation facility did not give resident medication according to Physician’s order is unsubstantiated meaning that 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 allegation is UNSUBSTANTIATED. No deficiencies were cited during today's inspection.