complaint·January 29, 2025

(continued from LIC9099) it indicated S1 needed to "maintain a professional demeanor with residents and refrain from discussing unrelated care matters with them." Staff 2 (S2) and Staff 3 (S3) had witnessed S1 speak to residents in a rude manner, however S1 has improved in how they interact with residents. Resident 1 (R1) stated S1 had spoke to them rudely in the past, however S1 is very nice to them now. While S1's demeanor with residents has improved, based on interviews and record review, the allegation S1 does not treat residents with dignity is Substantiated for the time frame this complaint was reported. Regarding the allegation residents missed medications: It was reported S1 was noting on the medication administration record (MAR) the bedtime medications for memory care residents had been given, however a NOC shift medication technician witnessed the medications remained in the top drawer and were not given. Later, the medications were gone. Bedtime medications are usually given at approximately 8:00 p.m. Staff assumed the medications were destroyed since it was too late to administer the medications but there was nothing noted on the MAR about residents missing their medications. Staff stated this happened on more than one occasion and it was reported to the previous ED. Staff was not sure if anything was addressed with S1 by the prior ED. In addition, a resident complained about being given their medications late by S1 and S1 received a disciplinary write-up with that noted. While S1's performance with medications has reportedly improved, based on interviews and record review, the allegation residents missed medications is Substantiated for the time frame this complaint was reported. Regarding the allegation medications were accessible to residents in care: It was reported while S1 passed out medications cups to the assisted living residents seated in the dining room for dinner, S1 would leave the medications cups on the table rather than wait for residents to take their medications. This was confirmed during interviews with other staff. In addition, this led to one resident taking another resident's medications. Staff stated they informed the previous ED of this medication error. While S1's performance with medications has reportedly improved, based on interviews, the allegation medications were accessible to residents in care is Substantiated for the time frame this complaint was reported. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.