complaint·January 13, 2025

Report Continued from LIC 9099... It was alleged that facility staff is sleeping during NOC shift. It was reported that staff will sleep 4 – 5 hours before getting up and assisting the residents in the morning. During the facility walkthrough, the LPAs observed that there was no camera in the 400’s hallway, and two rooms, 403 and 408, were both unlocked and vacant. However, the vacant rooms appeared clean during the walkthrough. Cameras were observed throughout the common areas and other hallways. During interviews with staff, they denied sleeping or observing other staff members sleeping during their shifts. Further interviews revealed that residents had not reported or made any complaints regarding a lack of assistance during the day or night. In interviews with residents, they denied observing or hearing about staff sleeping while working. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “facility staff is sleeping during NOC shift”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that facility staff do not treat residents with dignity and respect. It was reported that residents have reported staff being rude, disrespectful, and handling rough when assisting. Interviews conducted with residents revealed that the staff are friendly and have not been treated differently from the other residents. Additionally, residents denied experiencing disrespect from facility staff or witnessing staff disrespecting other residents during assistance. Furthermore, six out of six residents interviewed expressed no concerns or complaints about how the staff treat them. Based on interviews conducted with residents, the Department has insufficient evidence to support the allegation of “facility staff do not treat residents with dignity and respect”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided. Report Continued from LIC 9099... It was alleged that staff did not assist residents with self-administration of medication as prescribed. It was reported that medications are not being administered to residents at the appropriate times and other times medications are being left unattended causing residents to miss their dosage. On 03/11/2024, LPAs observed two random resident medications, the medication list, and the centrally stored medication and destruction records (CSMDR). According to Resident #1’s (R1’s) Medication List, dated 03/11/2024, it lists twenty (20) routine medications and eight (8) PRN medications for R1. Although R1’s Medication Administration Record (MAR) indicated that all prescribed medications were being administered, as the facility staff initials inidcated, certain medications such as Calcium Carbonate 1500mg, 600mg (1 tablet twice a day), Preservision AREDS Capsules (2 capsules daily), and Terbinafine HCL 250mg (1 tablet daily) were not observed or present with the other routine medications. Additionally, three (3) out of the eight (8) PRNs were found to be missing and not with R1’s medications. These missing PRNs included Albuterol Sulfate HFA 108, Mucus Relief 600mg, and Tizanidine HCL 4mg. Moreover, Resident #2 (R2) has a PRN medication, Albuterol Sulfate HFA 108 (inhale 2 puffs by mouth every 6 hours as needed for shortness of breath). However, during the medication review, it was revealed that R2’s PRN medication was empty and had not yet been refilled. Furthermore, residents’ medications were either missing or had not been refilled during medication review indicating residents are not taking their medications as prescribed. Based on medication review and LPAs observations, the Department has sufficient evidence to support the allegation of “staff did not assist residents with self-administration of medications as prescribed”. Therefore, this allegation is deemed Substantiated at this time. It was also alleged that facility staff is not sufficient in numbers and competent to provide adequate services to residents in care. Record review and interviews conducted revealed that Staff #1 (S1) was hired by the facility on 02/05/2024 and began working on 02/15/2024. According to the staff schedule dated 02/18/2024 – 03/03/2024, S1 worked the NOC shift on 02/23/2024, 02/24/2024, 02/25/2024, 02/28/2024, 02/29/2024, 03/01/2024, and 03/02/2024. Interviews also revealed that S1 had been assisting residents with their activities of daily living (ADLs) prior to reaching the age of eighteen (18). Report Continued on LIC 9099C... Report Continued from LIC 9099C... Furthermore, although two staff members were assisting residents, one of them did not meet the minimum qualifications required by state regulations. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “facility staff is not sufficient in numbers and competent to provide adequate services to residents in care”. Therefore, this allegation 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. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.