Inspector’s narrative
What the inspector wrote
Continued from LIC 9099
During today’s visit, the LPA briefly toured the facility with the administrator
On the allegations: “Staff are not providing activities for residents in care” The RP expressed concern that the lack of staff directly impacted the facility’s ability to offer scheduled activities to residents. Interviews conducted with the ED confirmed that the facility has been experienced staffing challenges. The ED explained that during staffing shortages front desk personnel assisted with resident activities as needed. Management acknowledged that, due to these staffing issues, the facility had been unable to consistently provide scheduled activities to residents in care until recently. Management further stated that as of Monday (05/05/2025) a caregiver has been formally assigned to lead activities while the facility continues to hire additional care giving staff. Caregivers interviewed corroborated this and also revealed that when the driver position became vacant, the Activities Director was temporarily reassigned to perform transportation duties, resulting in the cancellation of daily activities. Resident interviews supported these claims. Several residents stated that after the prior driver left, activities were minimal and often limited to sitting in front of the television doing stretching exercises, or informal singing led by residents. However, residents also expressed optimism, noting that as of Monday, the facility has resumed structured activities such as Bingo. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that scheduled daily activities were not being provided by the facility. Therefore, the above allegation “Staff are not providing activities for residents in care” is deemed SUBSTANTIATED at this time.
As to the allegation of Staff did not administer medication as prescribed and Staff did not safeguard resident's medications It was alleged that, due to understaffing, staff negligence, and an excessive workload, Resident #1’s (R1’s) eyedrops were missing for a couple of days, and medication prescribed for osteoporosis was missing for a few weeks, leading to a lapse in medication administration. Interviews with the Licensee and the ED revealed that for residents who are unable to manage their own medications, the facility stores the medication in the Med-Room.
Continued on LIC 9099-C
Continued from LIC 9099-C
Medication Technicians (Med-Techs) are responsible for ensuring proper administration, storage and timely refills of medications. Both the Licensee and ED acknowledge that the medication management system, particularly with regard to the Med-Techs and in-room storage, requires significant improvement due to instances of careless errors made by staff. Interviews with the Reporting Party (RP) reveal concerns regarding insufficient staff and prescribed medications not being administered as prescribed. Per RP, R1 allegedly received their medication dosage later than scheduled, with a second dosage administered earlier than directed. On one occasion, R1 did not received their prescribed P.M. medication due to facility staffing shortages. During interviews, Med-Techs reported that assigning a single individual to manage all responsibilities, including preparing medication, administering them in a timely manner, and overseeing prescription refills, is not sufficient to ensure safe and effective medication management. An internal review, along with staff interviews, revealed occasional lapses in medication management within the facility. Specifically, it was found that medications were not consistently stored in the med-room, administered and proper documented. Additionally, staff express concerned regarding insufficient training, lack of consistent oversight by management, and inconsistencies across shifts. LPA reviewed and compared on-hand pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR). Medication audit conducted revealed discrepancies where the pill counts within bubble packs did not match the records documented. These findings corroborate that the facility failed to appropriately safeguard residents’ medication. Morning Med-Tech on duty was unaware of these discrepancies, while evening Med-Techs reported uncertainty about how these errors occurred, stating that often there is a breakdown in communication, documentation and medication administration between shifts. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff are not administering resident’s medication in a timely manner. Therefore, both allegations “Staff did not administer medication as prescribed and Staff did not safeguard resident's medications” are deemed SUBSTANTIATED at this time.
Continued on LIC 9099-C
Continued from LIC 9099-C
As to the allegation of Insufficient staffing, it was alleged that R1 did not received their prescribed P.M. medication and daily activities due to facility staffing shortages. It is the concern of the RP that due to ongoing staff shortages the facility is not providing adequate supervision and care to the residents. Interviews with the Licensee and the ED confirmed that the facility has experienced staffing challenges. However, both the Licensee and the ED stated that the facility maintains sufficient staffing levels to cover for employees who resign or call out due to illness using caregiver from a staff agency. Residents interviewed stated that staffing deficits have directly impacted the quality and timeliness of care provided to them. Specifically, concerns have been raised regarding delays in medication management, including missed or late medication administration, as well as extended wait times for resident assistance. Interviews with staff revealed ongoing concerns related to workload and staffing levels. Staff reported feeling overworked, stressed, and overwhelmed due to persistent staffing shortages. They indicated that they are frequently required to assume additional responsibilities and take on extra shifts. Staff reported that this level of understaffing has led to them rushing through tasks leading to careless errors related to medication administration, missing timelines, delays in assisting residents, and longer response times to resident call signals. To further investigate these concerns, LPA conducted a comparison of staff schedules, timecards, and personnel reports (LIC 500). The review confirmed that facility has occasionally employees calling out of their schedule resulting in other staff members being required to work double shifts. In certain instances, employees were asked to report to work on their scheduled days off to ensure adequate coverage. Additionally, the LPA observed staffing gaps during shifts, with only two (2) caregivers and one (1) Med-Tech on duty to provide care for all residents including the Meadows (Memory Care). Based on information gathered during the course of the investigation, there is sufficient evidence to determine that shortage of staff is causing medication issues and longer wait times. Therefore, the above allegation “insufficient staffing” is deemed SUBSTANTIATED at this time.
Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.
Continued on LIC 9099-C
Continued from LIC 9099-C
A $250 immediate repeat civil penalty for the citation related to CCR 87411(a) is assessed today. Another $250 civil penalty is assessed for the citation related to CCR 87465(a)(4) for a repeat violation. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f).
Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.
