Complaint Investigation Report

LPA reviewed the Medication List and determined that the medication that was missed was supposed to be administered on certain days including the day of April 17, 2022. Facility failed to administer the medication based off of physician’s instructions (See LIC 9099D) . During the Document Review of the Medication Assessment Record (MAR), LPA observed the medication documentation was not accurate due to the facility staff missing a medication pass and not properly documenting the medication that was missed on April 17, 2022. In addition, the staff member that missed the medication pass did not communicate to upper level management regarding the missed medication for that day nor document in the MAR the missed medication (See LIC 9099D) .

Complaint alleges that Resident's care plan was not adhered to when facility failed to respond to Call Bell in a timely manner. During the course of the investigation, LPA reviewed facility records and learned that on April 17, 2022 the resident call bell was not responded to when pressed. The resident had to wait 1 hour and 40 minutes before a staff member responded to that call bell (See LIC 9099D) .

Complaint alleges that there are unqualified staff at the facility. During the course of the investigation, LPA conducted interviews and reviewed facility records and learned that 9 staff members have not had the required training hours as specified in regulation (See LIC 9099D) .

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Resident Relations Director, Linda Nguyen .