Complaint Investigation Report

Allegation: Staff does not administer medication as prescribed. Review of R1's medication administration record did not indicate R1 was being given any excessive amounts of Lorazepam. LPA reviewed the medication administration record for R1 and did not find any medication errors for R1 or any other resident record reviewed. LPA reviewed five other residents' records. Based on this information LPA was unable to identify any other medication errors. The allegation is unsubstantiated

Allegation: Staff did not properly supervise resident causing resident to fall. Based on records reviewed R2 did have a fall on 9/20/2023 and was sent to the ER, R2 was not on a stand assist for toileting or dressing. The facility did assess R2 for fall risk and it was not targeted as support. The facility revised the service plan to support R2 as a fall risk after this incident. R2 has a new service plan that addresses the potential for falls. The allegation is unsubstantiated.

Allegation: Staff left resident in disrepair bed. Based on records reviewed the department was able to determine that on 8/21/2023, R2's bed was making a squeaking noise when R2 would move, Staff heard the noise and went to inspect the bed and noticed that the bed was broken(a support beam was loose). Staff notified the maintenance director and the bed was replaced. The duration of how long the bed was making noise is unknown.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. The Department has determined that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22