complaint·July 31, 2024

Facility mis-managed a resident's medication - UNSUBSTANTIATED It was reported that Resident 1 (R1) had a large amount of prescription medication left over when they passed. Complainant would like to know if facility over ordered or did not dispense the medication to R1. LPA reviewed R1’s Medication Administration Record (MAR) for the month of March 2024 which revealed that all medications were dispensed as prescribed throughout the month. Executive Director stated The medications were R1’s back stock. Five medications for the next months, plus for the cycle fill. They were R1’s back up meds from the pharmacy. We tried to give it to the family and they told us to dispose of it. There was more in the back stock and they said we should get rid of it. It was determined that R1’s medication was ordered and dispensed as prescribed. This allegation is unsubstantiated. Continued on LIC9099-C Reporting requirements to family not followed - UNSUBSTANTIATED It was reported that R1’s family requested a written explanation of the events that led to R1 being hospitalized and the facility did not supply the written explanation but referred the family to call the company’s 800 compliance line to request documentation. LPA reviewed incident report that was submitted by the facility to licensing on 04/09/2024. It was reported that on 04/03/2024 at approximately 7:00 pm med tech was going to R1’s room to deliver their evening medication and observed R1 turning blue and non-responsive. Med tech called 911, R1 was transported to ER for further evaluation and subsequently admitted to ICU for observation. Med tech notified family of the incident. LPA reviewed LIC624A Death Report dated 04/12/2024 that states R1 was admitted to hospital on 4/3/24 for fluid in their lungs and admitted to ICU for observation. Date of death 4/8/24 pronounced by hospital nurse. Executive Director stated On 4/03/24 R1 went to hospital. A family member came to the facility on 4/09/24 and advised that R1 had passed that morning at the hospital. The family requested documentation. Any time the ED is asked for documentation they have to get clearance from their supervisor. When the ED requested clearance, she was told the family would have to request it through the compliance line at the home office. ED gave the family the compliance line telephone number. It was determined that the facility did notify the family when R1 had a change of condition and was transported to the ER. The family notified the facility of the passing of R1 at the hospital, it is standard protocol for hospital to notify the family of death and not to notify the facility. When the family requested an explanation in writing they were referred to the company’s compliance line. Although this does not meet the preponderance of evidence standard for substantiation of the allegation, the facility should review their protocol of supplying information in writing to families upon the death of a resident should the family make that request, which is not unreasonable. This allegation is unsubstantiated. Continued on LIC9099-C Reporting requirements to licensing not followed - UNSUBSTANTIATED LPA reviewed incident report that was submitted by the facility to licensing on 04/09/2024. It was reported that on 04/03/2024 at approximately 7:00 pm med tech was going to R1’s room to deliver their evening medication and observed R1 turning blue and non-responsive. Med tech called 911, R1 was transported to ER for further evaluation and subsequently admitted to ICU for observation. Med tech notified family of the incident. LPA reviewed LIC624A Death Report dated 04/12/2024 that states R1 was admitted to hospital on 4/3/24 for fluid in their lungs and admitted to ICU for observation. Date of death 4/8/24 pronounced by Hospital Nurse. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to Crystal Villalobos - Memory Care administrator and Sonya Gonzales Executive Director.