complaint·July 16, 2025

Continued from LIC 9099 Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: It was reported that “Staff are mismanaging residents’ medications”, as it was reported that the facility does not have sufficient staffing to properly care for residents and that medications were not being administered. Additionally, it was alleged that memory care residents were being left alone in their rooms to manage their own treatments. An interview with the ED confirmed that, during staff shortages, the facility relies on staffing agencies to provide temporary caregivers as needed to fill vacant positions or cover staff call outs. This is being done to ensure that staffing levels remain adequate to meet residents’ needs. Interviews with residents revealed that the facility had been experiencing challenges maintaining consistent staffing levels. Some residents expressed dissatisfaction with the frequent turnover of caregivers; however, they confirmed that their medications were being administered on time and on a daily basis. Staff interviews acknowledged ongoing staffing challenges, with some staff reporting they are occasionally required to take on additional responsibilities or work extended shifts. Despite feeling overwhelmed at times staff emphasized that resident needs are being met and medications are dispensed on time. Staff also denied leaving residents unattended during treatment times. Furthermore, staff reported that they follow physician orders regarding the administration of medications, including when medication must be crushed or dissolved. Interviews with credible witnesses, including family members, indicated that their loved ones are receiving appropriate care, and no concerns regarding medication management were reported. Additionally, LPA selected seven (7) random residents and conducted a comparison of the centrally stored medication log and medication supply in the medication room was conducted. No discrepancies were observed. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations ““Staff are mismanaging residents’ medications” is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued. Continued from LIC 9099 LPA Conway interviewed the ED, two (2) Med-Techs, one (1) resident, and reviewed and obtained documents pertinent to the investigation. The Reporting Party (RP) was anonymous therefore, the LPAs were unable to obtain additional information regarding the allegations. Throughout the course of the investigation, LPA Conway reviewed all documents obtained, conducted telephonic and in person interviews with additional credible witnesses and other relevant parties. The following was then determined: It was reported that “Staff did not ensure facility door was not in disrepair” as it was alleged that the front door of community was not functioning and that no corrective action had been taken to address the issue. During the course of the investigation, interviews revealed that the automatic system for the main entry double doors did not consistently engage when the ADA push plate was activated, preventing the doors from opening automatically. This malfunction was challenging for residents using wheelchairs, walkers or any mobility devices, as well as for staff and visitors to safely enter and exit the facility. An interview with the ED acknowledges that the main double doors had been experiencing issues. However, as so on as the problem was identified, a third-party vendor was contacted to assess and repair the doors. Furthermore, the ED stated that while the doors were not functioning properly, staff and front desk personnel assisted residents who requested and/or required help entering or exiting the facility. On 12/23/24, the diagnosis revealed that the transfer hinge wires were broken, and a new motor drive reaction kit had to be ordered. During this visit, a temporary adjustment was made, and the vendor recommended ordering new parts. On 12/30/24, adjustments were made to the solenoid latch, followed by additional repairs on 1/6/25 and on 1/15/25. On 2/20/2025, the vendor returned and installed a new motor drive retraction kit and replaced broken wires. After the repairs were completed, the main double doors were tested and found to be functioning properly. Continued on LIC 9099-C Continued from LIC 9099-C Documentation gathered during the investigation, including work orders and invoices, supports the information provided by the ED, however, during today’s visit, the LPA observed a sign posted on one of the main double entrance doors that read “Please use other door”, with an arrow pointing to the opposite door. The ED stated that the motor of the ADA push plate device is broken. A replacement part has been ordered, and repairs are scheduled to be completed on 07/17/2025. Between 2:05 P.M. and 3:00 P.M. LPA interviewed staff and residents, who reported that the door has been experiencing intermittent issues for several months and has remained in disrepair for the past two (2) weeks. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that main doors were malfunctioning and the automatic system was not functioning properly. Therefore, the above allegation “ Staff did not ensure facility door was not in disrepair ” 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 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.