Complaint·May 24, 2023

Allegation: Medications not given to resident timely The allegation alleges on 06/05/2021, staff only brought Resident #1 (R1) three of R1’s AM medications when R1 receives more than three AM medications. When R1 questioned where the other medications where, staff stated they would return with them. It was alleged after lunch, R1 still had not received the missed AM medications. Medication record review revealed, R1 received ten (10) AM medication to be dispensed at 9:00 AM. Medication Passing Detail records for R1 on 06/05/2021, revealed R1 received six (6) of their AM medications at 9:00 AM and four (4) of their AM medications at 12:24 PM. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Medications not given to resident timely' is deemed Substantiated at this time. Allegation: Staff mismanaged resident's medication The allegation alleges R1 did not receive all their medications and facility staff acknowledged they failed to order R1's medications timely. Medication Passing Detail records for R1 revealed R1 did not receive two (2) AM medications on 06/06/2021 (Asprin and Losartan Pot 50 MG) due to the medication being on route for delivery. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff mismanaged resident's medication' is deemed Substantiated at this time. Allegation: Staff does not respond to pendent calls timely The allegation alleges residents have to wait 20 minutes or longer for staff to respond to pendent calls. During the investigation, the LPA interviewed six residents. Five out of the six residents interviewed used their pendent when they need assistance and reported they sometimes have to wait 20 minutes to over an hour for staff to respond to their call. Pendent call records were reviewed for 05/14/2021 through 06/14/2021 revealed the following. Report continued on LIC 9099-C. On 05/23/2021 and 05/14/2021 R2 had to wait 20 minutes for staff response; R4 had the following wait times, on 05/15/2021 24 minutes, 05/18/2021 30 minutes, 05/21/2021 36 minutes, 05/31/2021 32 minutes, 06/08/2021 28 minutes, 06/11/2023, 20 minutes, and 06/14/2021 22 minutes, R6 had the following wait time, on 06/01/2021 45 minutes, 06/02/2021 22 minutes, 06/02/2021 58 minutes, 06/03/2021 29 minutes, 06/03/2021 35 minutes, 06/04/2021 1 hour and 16 minutes, 06/05/2021 53 minutes, 06/07/2021 1 hour 2 minutes, 06/08/2021 1 hour 4 minutes, 06/10/2021 1 hour 19 minutes, 06/10/2021 32 minutes, 06/11/2021 1 hr 12 minutes, 06/14/2021 40 minutes. During the 06/14/2021 visit, the LPA met with Business Office Manager at the time Annabel Amaya, who reported they did have issues with staff at the time and were in the process of hiring additional staff but were using agency staff to help supplement. Ms. Amaya said staff should be responding within 10 minutes to pendent calls. During the interview with S1 they stated recently due to there being only one staff (S1) and one agency staff on shift, they did not respond timely to R6 and it took over 30 minutes for S1 to respond. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore the allegation of 'Staff does not respond to pendent calls timely' is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller. A copy of the report and appeal rights were provided. Allegation: Staff falsified facility records The allegation alleges Staff #4 (S4) on 06/05/2021, S4 documented on R1's records that all their medication had been given that day when it had not. Record review revealed on 06/05/2021, Staff #5 (S5) dispensed the AM medications and not S4. On 06/06/2021, S4 documented R1 did not receive two medications because they were on order from the pharmacy. Both S4 and S5 no longer work for the company. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff falsified facility records' is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report provided.