During the course of the investigation LPA Jensen inspected the medication room. LPA Jensen observed 2 plastic cups containing multiple pills. Each cup had the number 12 on it and a resident’s first name only. LPA Jensen interviewed the Medication Technician on duty and inquired why the medication was there. The Medication Technician stated that it appears the Medication Technician attempted to administer the medication at noon the prior day but was unsuccessful for some unknown reason. LPA Jensen reviewed the Medication Administration Record (MAR) for the residents in question and determined that the medication was signed off on as having been administered. LPA Jensen’s findings were verified by a physical count of the medications. In addition, the facility submitted an incident report to advise that all of the February 2024 MAR had gone missing without explanation. It should be noted that the records went missing at approximately the same time that 2 employees were facing disciplinary action and were subsequently separated from employment with the organization. Based on the inaccurate MARs, missing MARs and medication not administered without explanation the allegation of staff mishandled resident’s medications is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Staff do not provide a comfortable temperature for the residents

LPA Jensen interviewed a resident that stated the room is very cold in the mornings and that there is no thermostat in this particular unit. The resident further stated that this issue has been brought to the attention of staff and for this reason the resident has extra blankets. LPA Jensen interviewed the Maintenance Director who stated there was previously an issue with the heat but was addressed immediately and repaired within a week. The Maintenance Director also stated that there is currently a problem with the air conditioner and the repair is pending management approval. LPA Jensen reviewed maintenance records and invoices and determine that on 3/22/24 an invoice from a mechanical vendor states “While performing your routine maintenance, Lakeside technician found the following: Swamp cooler needs a new motor which has been shorted to the ground.” Based on the resident interview and maintenance invoice reviewed the allegation that staff do not provide a comfortable temperature for residents is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

During the course of the investigation LPA Jensen reviewed 8 of 34 resident files. 2 of 8 resident files did not have any Needs and Service Plan. Resident 7 was admitted on 3/13/23 and did not have a Needs and Service Plan and Resident 8 was admitted on 8/24/23 and did not have a Needs and Service Plan. Based on LPA Jensen's review of the resident files lacking a Needs and Service Plan the allegation of "Facility is not reassessing residents to ensure needs are met" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. While the residents may have had a pre-placement appraisal.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, appeal rights and a confidential names list was given.

LPA Jensen was working in the facility TV room which is in proximity of the kitchen. LPA Jensen overheard a resident go to the kitchen and request “just a little red juice”. The kitchen staff told the resident, no, you can’t have that. You have ice water in your room. LPA Jensen went to the kitchen and asked staff 1 (S1) if the resident can have juice. S1 advised LPA Jensen she was told no because she has ice water in her room and because of the sugar content as she is diabetic. S1 went on to explain that residents can have juice in the morning at breakfast but not throughout the rest of the day to bring to their room as that is the policy. LPA Jensen asked to see the modified diet list to verify whether or not the resident’s name was on the diabetic list. The kitchen manager (S2) interjected and said she is not diabetic. LPA Jensen asked if she can have juice. The kitchen manager said yes but in the dining room, just not in the bedroom. LPA Jensen asked why the resident was told no as opposed to offering her juice to have in the common area. The kitchen manager stated S1 should have offered and it was a mistake not to. LPA Jensen conducted interviews with 10 residents and 10 of 10 residents deny that there access to fluids is restricted. LPA Jensen observed bedside drinking cups in every resident room in the facility. Based on LPA Jensen’s interviews conducted and LPA Jensen’s observations of drinking water in the bedrooms, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. However, based on the interaction between kitchen staff and the resident that asked for juice a personal rights violation did occur and is being addressed on a separate case management.

Staff interrupt the residents while sleeping

LPA Jensen conducted interviews with 10 residents and 10 of 10 residents deny that staff interrupt their sleep. LPA Jensen interviewed a former NOC shift staff member who stated that she did not awaken residents unless necessary. The NOC shift staff stated that if a resident had a closed door the protocol was to knock and wait for a response. If there was no response the room was entered for a health and safety check and the resident would be awoken only if necessary for example if incontinence care was required. All residents interviewed were satisfied with the care they are receiving and none stated that staff disturb them . Based on the interviews conducted and a review of facility policies the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it

LPA Jensen interviewed 10 residents and 1 resident family member. The majority of residents stated they have had no issues with their personal belongings being mishandled. 1 of 10 residents stated that his clothing disappears and reappears. 1 of 10 residents stated that her door remains locked to prevent any items from disappearing due to a resident that has a habit of wandering in to other client’s rooms. LPA Jensen interviewed a housekeeping staff member who explained that only a single resident's laundry is washed per load. All clothing that can labeled is labeled. After clothing is washed and dried it is hung up and organized based on room number. LPA Jensen reviewed facility training and staff are trained on housekeeping and the theft policy annually. While it is possible that at some point an item was inadvertently misplaced the allegation of staff mishandled the residents personal belongings is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report and appeal rights were provided.