complaint·September 14, 2024

On the allegation "Staff does not refill residents medication in a timely manner"; it is the concern of the reporting party that Staff #1 does not refill the residents medication in a timely manner. To investigate the allegation the LPA conducted a medication audit for four (4) out six (6) residents, observations and interviews. During the medication audits the LPA observed all prescribed medications to be filled, and the administrator informed the LPA that a refill had already been submitted for the medications with low quantities, such as a resident #2's (R2's) Haloperidol. During today's visit the LPA observed R2's Haloperidol medication being delivered. Staff interviews revealed that when the residents have about 10 days left on medications they will notify the administrator, so the administrator can get the medications refilled, and that the resident have not gone without medications due to them not being refilled in a timely manner. Staff interviews also revealed that a Hospice nurse comes twice a week and they let the nurse know every time a resident needs a refill. The Administrator stated that they have never run out of medications, and that if they are ever very low on any medication they would place a STAT order with the hospice nurse or resident's physician and get a same day order delivered. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. On the allegation "Staff mismanaged residents medication"; it is the concern of the reporting party that Staff #1 (S1) administers medication (Lorazepam and Haloperidol) to residents that are not prescribed to them. It was further reported that if a resident is feeling agitated and S1 does not have the medication prescribed to them, S1 would use another residents medication. To investigate the allegation the LPA conducted observations, medication audit, and interviews. On 09/06/24, when a resident was agitated the LPA observed staff provide medication to the resident. The LPA verified that it was the resident's prescribed medication, and correct time to provide. Medication audit conducted on 09/14/24 revealed that only two (2) residents take lorazepam, one (1) resident takes haloperidol. The medication was centrally stored and documented on the Centrally Stored Medication and Destruction Record (CSMDR) and there was nothing observed to suggest that their medications are being provided to other residents. Staff interviews revealed that they have never seen S1 administer medications to residents that are not prescribed to them. In addtion, S1 denied ever giving residents medications that were not prescribed to them. Furthermore, interviews with residents family members revealed that they have no concerns regarding the residents medications. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C (3rd page). On the allegation "Staff does not ensure that an adequate food supply is maintained on premises"; it is the concern of the reporting party that 2-3 weeks have gone by where there is no groceries or wipes for residents. It was further reported that staff members would purchase or sometimes order take out and that the residents complain they’re hungry. To investigate the allegation the LPA conducted a plant tour and interviews. On 09/06/24 and during today's visit, the LPA observed a sufficient amount of perishable and non-perishable food at the facility. The LPA also observed that snacks such as fruit and beverages were available for the residents. When the LPA arrived during today's visit the LPA observed three (3) residents at the kitchen table that had just finished eating breakfast. The LPA observed staff asking the the residents if they wanted any additional food, and provided cookies. In addition, during today's visit, the LPA observed staff cook and provide a squash side dish, paired with a macaroni and corn salad, and a taco from taco bell for lunch. Staff encouraged the residents to eat, and continue to offer other options. Staff interviews revealed that they always have food at the facility and the residents are not left hungry. If there are ever running low on supplies staff will notify the administrator, and they provide a list of things that are needed to the administrator every Monday and Friday. The administrator stated that the residents are never left hungry, and they are provided a variety of food. They went on to state that they order take out once a week, usually on Saturday's for lunch to give the resident's more variety in their food, but always pair it with vegetables and fruits to make it a balanced meal. Furthermore, all interviews conducted with residents family members revealed that they visit the residents once a week, and they have no concerns with the care being provided by the staff, and are very satisfy with the care provided including the meals. One of the family members revealed that they are pleased that the residents get fresh food, and have no concerns residents are being left hungry Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation occurred, therefore this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and provided. On the allegation " Staff does not properly discard deceased residents medication. "; it is the concern of the reporting party that when residents pass away staff #1 (S1) would not properly discard the medication and saves the medication in boxes. To investigate the allegation the LPA conducted a medication audit on 09/06/24. During the medication audit, the LPA observed four (4) different medications that were prescribed to a resident (R1) that had passed away on 08/07/2024 stored in a locked night-stand in the garage. The medication was among other extra medications for current residents, that had not been administered or discontinued. Upon observation, S1 stated that they were not aware that the medication for R1 was there and did not know what to do with the medication. Based on observation the allegation that Staff does not properly discard deceased residents medication is Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).Exit interview conducted. Today's reports and appeal rights were reviewed and issued.