Complaint·January 10, 2022

Regarding the allegation: Staff made inappropriate sexual advances to resident in care It was alleged that Staff #1 (S1) made sexual advances towards R1. A file review revealed that a similar allegation was made in complaint control # 29-AS-20210603101611, in which R1 made claims that staff at this facility were sexually abusing them. That allegation was unsubstantiated. Interviews with witnesses, staff, and residents negated claims that this took place. During that investigation, the LPA interviewed S1, whom commented that R1 continually made allegations that S1 was a ‘homosexual’ and making sexual advances toward R1, yet S1 repeatedly negated these claims and stated that the claims made them uncomfortable. Interviews conducted with staff revealed that they have not observed their coworkers acting inappropriately with residents, and were trained to report all types of abuse, both observed, overheard, and/or disclosed. Regarding this complaint, it was confirmed that S1 no longer works at this facility due to the repeated claims. Resident interviews revealed that residents feel comfortable residing in this facility and believe they are being treated well. Residents denied claims of abuse from staff and stated that staff maintained appropriate relationships and boundaries with the residents. Based on the investigation, there is insufficient evidence to support the claim that staff made inappropriate sexual advances to R1. This allegation is deemed Unsubstantiated at this time. No deficiencies cited regarding this allegation at this time. Exit interview conducted. A copy of the report was issued. Regarding the allegation: Staff are not administering medication(s) to resident according to physician’s instructions. It was alleged that R1 was not getting their medications consistently. Interviews with residents revealed that in general, they believed they received their medication on time and were unaware of any errors. During the medication audit conducted on 11/19/2021, it was revealed that the facility could not account for R1’s Atorvastatin, as it was not centrally stored with R1’s other medications. Staff interviews revealed that when the Atorvastatin was delivered, R1 got upset that it was being centrally stored and allegedly argued with Staff #2 (S2) about the medication. As such, S2 admitted that they gave R1 the medication to store in their room. As such, staff were unable to ensure that R1 was taking the Atorvastatin according to physician’s instructions. In addition, a review of the Centrally Stored Medication and Destruction Record (CSMDR) revealed that R1’s prescribed evening dosage of Quetiapine (Seroquel) was documented as Refused in the section Start Date . Interviews further confirmed that R1 had a prior history of refusing the evening dosage of Quetiapine. As such, rather than offer R1 their evening medication of Quetiapine and giving R1 the option to refuse, S1 admitted to not giving R1 their evening medication as prescribed on 11/19/2021. S1 claimed that they stored it in their room, and then threw the medication away. The LPA could not identify evidence to demonstrate that R1’s repeated refusal was communicated to R1’s primary care physician. During a visit conducted on 11/19/2021, LPA Smith was granted access to tour R1’s room. The LPA observed several loose pills in R1’s drawer, which were identified as Quetiapine pills. In addition, the LPA observed two bottles of medications. One medication was identified as Crestor, and the other pill box had a mix of multiple unidentified medications. After touring R1’s room, the LPA alleged that the loose Quetiapine pills were from times in which staff attempted to assist R1 with the evening dosage of Quetiapine and rather than observing R1 taking the medication, the pill(s) were left with R1 and staff assumed that R1 took the medication. Based on the investigation, there is sufficient evidence to support the claim that staff were not assisting R1 with the self-administration of medication(s) according to physician’s instructions. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report, and appeal rights, were issued.