It was alleged that staff are not ensuring that residents are administered their medication(s) as necessary. More specifically, it was alleged that staff failed to ensure that Resident #1(R1) received their prescribed medications. Staff interviews revealed that medications, including insulin and oral prescriptions, were offered per physician orders and that refusals were documented in the MAR. Staff acknowledged that the resident frequently declined insulin and blood glucose checks, and that he was informed of the risks associated with non-compliance. Resident interview confirmed that he often refused insulin because he did not like how it made him feel and did not always communicate this to staff. The resident’s representative stated that the resident reported missed doses but also acknowledged his tendency to refuse care. Records review revealed consistent documentation of medication refusals and a temporary supply issue on 5/7/24, which was addressed by staff using community supplies and contacting the pharmacy and POA. LPA observations confirmed that staff were aware of the resident’s medication regimen and followed procedures for offering and documenting care.

It was also alleged staff are not ensuring that resident gets fed. More specifically, it was alleged that staff failed to ensure that R1 received meals as required. Staff interviews revealed that meals are served three times daily in the dining room and that residents are encouraged to attend. Staff stated that the resident occasionally declined meals due to personal preference or mood, but was always offered the opportunity to eat. Resident interview revealed that he sometimes chose not to eat because he did not want to be around others or was upset with staff. The resident’s representative stated that the resident reported missing meals but also acknowledged his tendency to isolate. Records review did not show consistent documentation of meal refusals or tray service, but there was no indication that meals were withheld. LPA observations confirmed that meals were being served during the visit and that residents were present in the dining area. Staff were observed offering meal options and encouraging participation.

It was also alleged staff are forcing resident to stay in their room. More specifically, it was alleged that staff restricted R1 to his room. Staff interviews revealed that the resident was encouraged to remain in his room during periods of agitation or after altercations with peers. Resident interview revealed that he felt isolated and believed staff were intentionally keeping him in his room. Outside source interview confirmed that the resident reported being told not to leave his room. Records review showed documentation of one-to-one supervision and safety checks, but no formal room restriction orders. LPA observations revealed that the resident was in his room during the visit and stated he was told not to come out. (continued on LIC9099c)

It was also alleged, the staff are preventing residents from participating in private visitations. More specifically, it was reported that R1 was not allowed to have private visits in his room with R2. Interviews with staff revealed that the Executive Director (ED) advised RP that R2 should not be in R1’s room due to safety concerns, but confirmed that staff did not physically prevent visitation. Staff #1 confirmed that R2 had been in R1’s room and that management had only discussed safety concerns with R1. R1 stated during the interview that he was frustrated about visitation limitations, but did not report being physically prevented from seeing R2. RP did not provide evidence that staff enforced a restriction. No outside sources provided information to support that visitation was restricted. A review of facility records revealed no documentation indicating that staff restricted or denied private visitation. Facility policies do not prohibit private visits in resident rooms. LPA observations confirmed that R1 was seen interacting with other residents and family members and had access to his room and outdoor areas

An exit interview was conducted with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee staff. An exit interview was conducted, along with with Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.