complaint·April 22, 2025

Continued from LIC 9099 Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined: As to the allegation of, staff did not refill resident’s medication timely resulting in resident missing medication and staff are not giving residents medication as prescribed. It was alleged that, due to staff neglect and workload, Resident #1 (R1) ran out of blood thinner, eyedrops and bone density medication, leading to a two-day lapse in medication administration. Interviews with ED and RSD revealed that for residents who are unable to manage their own medications, the facility stores their medication in the Med-Room. Medication Technicians (Med-Techs) and nurses are jointly responsible for ensuring medication refills are processed in a timely manner. According to facility protocol, refill requests for external pharmacies are to be faxed 27 days in advanced, while those using the facility’s preferred pharmacy must be requested at least 14 days in advance. Interviews with R1 revealed that although the resident is able to communicate their needs clearly and follow instruction, they are not capable of independently managing or administering their prescribed medications. The investigation confirmed that a lapse in medication occurred because staff failed to send a refill request to the pharmacy in time. It was discovered through interviews that neither the Med-Techs, nor the RSD adhere to physician’s instructions regarding timely medication refills. As a result, of the failure to timely refill prescriptions, R1 missed scheduled daily doses of prescribed medication. During interviews, a Med-Tech revealed that the nurse on duty had verbally assumed responsibility for placing the refill order. However, upon request by the LPA, no written documentation could be produced to verify that the nurse or any other trained staff had faxed, emailed or otherwise contacted the pharmacy prior to the depletion of R1’s medication supply. Medication audits were conducted on 12/31/2024, 03/20/2025 and 04/10/2025. During these audits, pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR) were reviewed for ten (10) randomly selected residents. Continued on LIC 9099-C Continued from LIC 9099-C The LPA found discrepancies in eight (8) out of ten (10) resident’s medication, where the pill counts within bubble packs did not match the records documented on the CSMDR. Morning Med-Techs on duty were unaware if these discrepancies, while evening med techs reported uncertainty about how these errors occurred, stating that often there is a breakdown in communication, documentation and medication administration between shifts. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff are not refilling resident’s medication in a timely manner. Therefore, the above allegation “staff did not refill resident’s medication timely resulting in resident missing medication and staff are not giving residents medication as prescribed,” is deemed SUBSTANTIATED at this time. As to the allegation of insufficient staffing. It was alleged that a decline in staff morale from management, has contributed to an increase in staff resignations. As a result, ongoing staff shortages have been reported. Interviews with ED confirmed that the facility has experienced staffing challenges. However, the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness. Furthermore, the ED explained that both the Resident Care Coordinator and the Resident Service Director are qualified to performed Med-Techs duties and are available to provide coverage when needed. In addition, most Med-Techs are cross-trained in caregiving responsibilities and can be scheduled to assist on the floor as necessary to ensure co ntinuity of care. Residents interviewed stated that staffing deficits have directly impacted the quality and timeliness of care provided to them. Specifically, concerns have been raised regarding delays in medication management, including missed or late medication administration, as well as extended wait times for resident assistance. Interviews with staff revealed ongoing concerns related to workload and staffing levels. Staff reported feeling overworked, stressed, and overwhelmed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts, often with little advanced notice from management. Additional information provided by staff to the LPA indicated that occasionally a single staff member is assigned to cover all 3 floors of the Assisted Living unit. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless errors related to medication administration, missing timelines, delays in assisting residents, and longer response times to resident call signals. Continued on LIC 9099-C Continued from LIC 9099-C To further investigate these concern s, LPA conducted a comparison of staff schedules, timecards, and personnel reports (LIC 500). The review confirmed that facility has occasionally employees calling out of their schedule. Also, multiple employees are no longer working at the facility, resulting in other staff members being required to work double shifts. In certain instances, employees were asked to report to work on their scheduled days off to ensure adequate coverage. Additionally, the LPA observed staffing gaps during shifts, with only one (1) caregiver and one (1) Med-Tech on duty to provide care for all residents in the assisted licing unit. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that shortage of staff is causing medication issues and longer wait times. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the foll owing deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.