During interviews with the residents, 4 out of 7 confirmed the allegation to be true in general and specific to 12/05/2021. R3 states, “No! I moved in June and what they were offering prior to moving in were things we thought we needed but many of those services are not available. The staffing is low and often not available. R4 states, “they’re trying, it’s a new facility, but they need to work a bit harder at getting things done. They are understaffed in my opinion.” R5 states, that day (12/05) I don’t know what was happening. No one was showing up.” R6 states, “that Sunday, no one came to help me.”

During interviews with witnesses, they generally confirm the allegation to be true. W1 states, “yes, in relation to not being skilled staff. There are people available that don’t meet the needs of the residents and are not qualified to support. They have well intentions.” W2 states, “yes, I know for a fact. There is no RN at the facility. There is no one to oversee the medication administration program.” During a review of the schedule for December 2021, LPA observed only one staff scheduled the morning of 12/05/2021.

Regarding the allegation: Facility did not dispense residents' medications according to doctors' orders. It’s being alleged, “on 12/05/2021, residents of the community and families called with concerns of their loved ones not being assisted when needed for medications. Due to the insufficient staffing and lack of communication from management there was unfortunately no Med Tech scheduled for Sunday, December 5th.” The investigation revealed the following: During interviews with staff, 3 out of 6 confirmed the allegation to be true. S2 states, “they didn’t get their medication for Sunday morning.” S4 states, that morning I didn’t give the morning meds because the time had passed. I started clearing pendants. The residents were asking what was going on and where was their medications. Some of the residents refused due to the fact that the

Cont. on 9099C

During interviews with residents, 4 out of 7 generally confirmed the allegation to be true. R1 states, “when I first got here there was some confusion about my medication. Some of which was missed.” R5 states, there was one day when we missed our meds, but it was made up for later that day. I missed one round of medication, but it was made up for by noon. I think S4 was involved in giving them to me.” R6 states, “they missed my medication one day last week. I don’t remember the day, but I didn’t get my morning meds.” R7 states, “yes, they didn’t have enough staff one of these days and they missed my meds.”

During interviews with witnesses, they generally confirm the allegation to be true. W1 states, “I’ve been having major issues with them and the administration of medication system.” W2 states, “they don’t seem to be using Medco the way they said they would. I have voiced my concerns over and over again and have not heard anything from the facility. A little while back a med tech reached out to me inquiring about the milligram for a medication meant for one relative but was attempting to administer it to my other relative. The medication was a PRN that was discontinued. During a review of the medication administration records, LPA observed R1, R2, R4, R6, R7, all missed morning medication on Sunday, 12/05/2021.

Regarding the allegation: Facility did not have sufficient staff to meet the needs of residents. It’s being alleged, “the facility has inadequate staffing.” The investigation revealed the following: During interviews with staff, 6 out of 6 confirmed this allegation to be true. Acting Administrator / S1 confirmed that the facility was short staff on 12/05/2021 but generally the facility has “plenty of staff. We called in an agency too.” S2 states, “no there is not sufficient staff to meet the needs. I was told it was okay for 1 person to be with 4 memory care clients. What happens when you have to help other people in the bathroom, but you have 3 other people. You need at least 2 people in memory care.” S3 states, “no, especially for memory care. There is usually only one person on. It should be at least 2 staff in memory care but, it’s only one. Sometimes there’s only like 2 staff for the entire building on Friday and Saturday.” S5 states, “No, we need more staff for sure. There is not enough staff to help with all the residents.”

During interviews with residents, 4 out of 7 confirmed the allegation to be true. R3 states, “No, I mean the other day they only had 2 staff working the entire building. I had to shower myself. You had one gal running trying to answer to the needs of the residents and one in memory care.” R5 states, “no there isn’t enough. We Cont. on 9099C

During interviews with witnesses, 1 out of 2 confirmed the allegation to be true. W2 states. “yes, that’s always been on my mind. When I go to the memory care floor there’s only one staff attending to the residents. Even if there are only 3 residents and one has to go to the bathroom they need another staff there watching the other residents. They are so short staff that they have med techs taking out garbage.”

Regarding the allegation: Residents' emergency pendants were not responded to. It’s being alleged, emergency pendants were going off and not responded to. The investigation revealed the following: During interviews with staff 3 out of 6 confirmed the allegation to be true. S2 states, “the person at the front desk kept calling out the pendant numbers knowing that there was only one person working that morning.” S4 states, “correct, when there is no coverage or short staff no one is answering the pendants. That’s what happened on Sunday.” S6 states, “Yes, I wasn’t able to answer immediately because I could not leave memory care.”

Based on the investigators interviews with Acting Administrator/ S1, staff, residents, witnesses and a record review, the preponderance of evidence standard has been met, therefore the above allegations is found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.