complaint·October 21, 2022

Page 2 During the course of investigation, the Department obtained copies of R1’s records including but not limited to medical records, list of medications, LIC602A Physician’s Report, LIC601 Identification and Emergency Information, Medication Administration Records, Incident Report, Fire Department Incident Report/9-1-1 call. The Department reviewed R1’s medications list, checked medications, and conducted interviews. On 11/30/2021, at approximately 0915 hours, facility staff called 9-1-1 to report that resident (R1) was unresponsive. The fire department arrived at 0919 hours and found R1 unresponsive with pinpoint pupils and shallow respirations. Due to the signs and symptoms, paramedics believed R1 was suffering from a possible opioid overdose. Staff denied R1 was on any narcotics but paramedics administered Narcan anyway. R1 had a positive response to the Narcan and was transferred to hospital. While at the hospital, the Emergency Department staff administered two separate urine tests, and both came back positive for opioid. R1 was discharged from the hospital on 12/05/2021 with diagnosis of opioid overdose. Staff (S1, S2 and S3) were interviewed. Staff denied providing R1 medication on 11/30/2021 and denied giving R1 wrong medication. Facility staff were unable to provide an explanation on how R1 had the opioid on R1’s system, stating someone may have given the medication while R1 sat outside or that it was provided by a family member two days prior. Family members (FM1 and FM2) were interviewed. FM1 was aware that FM3 visited on weekend prior to the incident and does not think the overdose will take effect two days after if FM3 has given something to R1. FM2 feels that the staff are the only people that have access to R1 aside from R1’s family. FM2 is confident that the siblings did not provide the medication to R1. .......continued on 9099C (page 3) Page 3 Residents (R2. R3 and R4) were interviewed. One of these residents, R2, indicated running into a few issues on medications. R2 stated staff have given R2 medications in a cup with name of other resident in the cup. R2 also indicated that some staff leave the medication room open and unattended, and some staff make sure the medication room is closed. During visits to the facility, the Department found the medication room door open and unattended on multiple occasions. The Department attempted to obtain video camera footage from the incident which Shalini Bhutani, administrator, reported was "accidentally deleted." Based on all information obtained during the course of investigation, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D, Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Nalini Bhutani. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.