Complaint·April 21, 2025

Regarding the allegation, “Staff did not follow medication protocol as prescribed” it is the concern of the reporting party that the staff at the community were not picking up Resident #1’s (R1’s) medicine from the pharmacy, were trying to give R1 different medications and not the correct brand and took away all R1’s pain rubs. Staff interviews revealed that they submitted refills and picked up R1’s medication on time, denied R1 was ever without medication due to the community not picking up their medication, and revealed that R1 could not store medications in their room due to their physician’s report. LPA reviewed records which indicated R1 refused medications many times and staff would notify R1’s physician. Charting notes and interviews with staff confirmed R1 was being provided their medication, however R1 would refuse due to medications being ordered by a different pharmacy than R1 was accustomed and the medication looked different even though the medication and dosage were the same. Furthermore, both of R1’s Physician Reports (LIC602) dated 07/25/23 and 08/07/24 indicated that R1 could not store their own medications. Lastly, all interviews with residents who are under medication management at the community revealed that they have no concerns regarding medications and have never been given the wrong medication. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, “Staff did not respond to resident's call pendent timely” it is the concern of the reporting party that Resident #1 (R1) pushes their pendant and has to wait for two hours before staff can help them go to the restroom. No date(s) provided. All staff and residents interviewed revealed that when a resident needs assistance they press the pendant that is on their person. Staff revealed that response time depends on different factors such as if they are assisting another resident at the time, or the time of day as mornings are usually busy, however all stated that they go ass soon as possible and they help each other out to ensure a timely response. Staff further revealed that R1 had a history of complaining that they waited a long time for assistance even though they assisted within 5 to 10 minutes, and that R1 would refuse their help and often not let them reset the pendant when they went to assist. All residents interviewed revealed that staff is very responsive, and they understand there are times staff cannot go right away but have not waited two hours for assistance as staff to go within minutes. LPA reviewed pendant records for R1 from 03/07/24, starting at 4:17 AM to 03/20/24 ending at 07:14 AM. R1’s pendant records revealed that out of 93 pendant calls R1 made, the staff average response time was 8.05 minutes, and the LPA did not observe any pendant response call times that took an hour or two hours to response. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Report will continue on LIC9099-C, 3rd page. Regarding the allegation, “Staff are not following client's special diet orders” it is the concern of the reporting party that Resident #1 (R1) is out of food for their special diet for their gastric issues. It was further reported that R1 makes their own food in the microwave, and they are out of food. On 04/18/25 at 12:00 p.m. the LPA observed residents eating lunch in the dining room. At 3:40 p.m. the LPA observed a diet board with all resident’s diets listed and sufficient food in the kitchen. Staff interview revealed that the community provides breakfast, lunch and dinner, as well as snacks, the kitchen is open from 7:00 a.m. to 7:00 p.m., the community has a bistro that always has snacks and drinks available, and there has never been a time that the community has ran out of food. All residents interviewed including those with special diets stated that they have no concerns regarding the food provided and staff knows what the residents can and cannot eat. Furthermore, staff interviews revealed that R1 was very particular about their food and bought their own food or the community bought them their own groceries, but the community always had food available and followed all the resident’s diets and even accommodated to the residents’ preferences. If R1 ever ran out of food they always had the option to eat the food provided by the community. Lastly, file review revealed that based on R1’s physician report R1’s special diet indicated no concentrated sweets, and R1’s Diet Fax Form dated 07/25/23 and signed by a physician indicated R1’s diet consisted of controlled carbohydrates, and regular texture. Interview with the communities Chef revealed that for a resident with a controlled carbohydrate they would ensure that everything is portioned, minimize carbs, and serve more veggies and protein if the special of the day was high in carbs, and that a dietician revises all of the menus. Based on interviews, observations and records reviewed this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, “Facility canceled resident's medical appointment” it is the concern of the reporting party that staff cancelled a Gastric medical appointment for Resident #1 (R1) at UCLA. LPA interviewed staff and all denied ever canceling any medical appointments for R1 or any resident and further stated that appointments would be cancelled either by the medical provider or the resident/authorized person. Staff stated sometimes R1 would refuse to go to scheduled appointments, cancel appointments or refused to be seen. LPA interviewed residents and none of them have ever experienced or witnessed staff canceling resident's medical appointments. Lastly, LPA reviewed charting notes dated 03/19/24 and 03/20/24 that revealed physicians canceling medical appointments with R1, Staff offering R1 assistance to set up appointments with a Gastroenterology, and R1 refusing staff's assistance. Based on interviews and file review this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Today's report was reviewed and provided..