complaint·August 7, 2025

Allegation: “Staff did not safeguard residents medications.” It was reported that residents’ medications were missing and were not centrally stored. The LPA conducted a medication review for four (4) residents. Medications were centrally stored in the Medication Room located on the first floor. Medications were checked for labels, expiration dates, and were properly stored on the centrally stored medication and destruction record. No errors were observed during the medication review. During the tour of the physical plant, the LPA observed Resident #1 (R1) had medications stored in their restroom. Medications included Milk of Magnesia, Amlodipine Besylate, Paroxetine HCL, Metroprolol, Ibuprofen, and Meclizine. Interview with staff revealed that R1 was allowed access to their nasal spray and inhalers, and reported that R1 did not have access to other medications. Record review confirmed R1 had physician orders to allow access to nasal sprays and inhalers to have stored at their bedside dated 10/24/2024. R1’s Physician Report dated 10/08/2024 stated R1 cannot manage or store their own medications. During the visit the LPA observed R1’s door remained open and staff stated R1 preferred to always have the door open and did not like being alone, which also allowed other residents to have access to R1's room. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. Allegations: “Staff did not ensure that resident’s hygiene needs are being met,” “Staff did not ensure that resident is provided clean bedding,” “Facility did not ensure that staff are properly trained,” and “Staff did not ensure that resident’s room is kept cleaned.” It was reported Resident #1 (R1) was left in their soiled clothes and bedding, and R1’s bedroom was not maintained cleaned. Interview with five (5) residents and six (6) staff revealed that housekeeping conducts a comprehensive cleaning of resident rooms once a week. Resident #2 (R2) stated the staff are very attentive and respond right away when they call for assistance. R2 has not had any issues with staff who did not clean their room. If Resident #3 (R3) has a spill, R3 expressed they notify staff who then respond quickly to clean it. Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) reported caregivers and housekeepers are responsible for the cleanliness of resident rooms. S4 stated caregivers assist with taking out the trash and picking up items off the residents’ floors, while housekeeping sweeps, mops, and vacuums in addition to other cleaning tasks. S1, S2, and S3 reported cleaning resident rooms daily and report to housekeeping if a resident needs a more thorough cleaning to which they respond immediately, sometimes later if they are in the middle of a task. Staff also reported bed sheets get changed every week during the residents’ laundry day, sometimes more often if needed. S1, S2, and S4 reported changing resident beddings when they observe or can smell that it has been soiled. Soiled beddings were addressed right away. S4 stated if they observed food on the bed, they would change the bedding or dust the food off, so the resident was not laying in it. Residents have scheduled showers, and the number of showers are determined based on their care plans. Staff #5 (S5) and the ED stated residents have been scheduled showers at least twice a week and have received more showers if needed. During today’s visit, LPA observed R1 to have clean bedding, clean clothing, and their room was previously cleaned the day prior. Staff stated they received mandated training upon their employment to the facility, with S3 reporting that they received two (2) months of training before directly assisting residents. The facility used Relias, a training platform, to conduct and track staff training. The facility has also conducted monthly self-paced module training through Relias. Report Continued on LIC 9099-C Additionally, the facility provided structured in-service training to all staff. S5 and the ED stated structured in-service training varies but is conducted every other week by the Department Heads or third-party consultants. Record review revealed that Staff received module and in-service training on topics including, but not limited to, medication, documentation and incident reporting, personal rights, skin integrity monitoring, and dementia. At this time, staff training requirements have been met. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency related to the allegations were cited. Exit interview conducted. A copy of the report was reviewed and provided.