complaint·December 23, 2024

Continued on LIC 9099-C Regarding allegation “Staff did not ensure that resident’s medication was refilled in a timely manner,” it was alleged that facility staff did not order Resident #1’s (R1) antibiotic Daptomycin medication timely. Information gathered during the course of the investigation reflected that Resident #1 (R1) was admitted to facility on 04/19/2024, following discharge from a medical center where they were treated for a bone infection. Upon admission, R1 had a Peripherally Inserted Central Catheter (PICC) and was prescribed the antibiotic Daptomycin, which was to be administered daily by an external Home Health (HH) nurse which continued until 4/25/2024. According to R1, on 04/25/2024, facility staff informed them that their supply of antibiotics was running low. However, when the HH nurse arrived the following day, 04/26/2024, to administer the antibiotic, it was discovered that the supply had run out. The HH nurse immediately advised the facility administrator, to transport R1 to the hospital to ensure they receive their daily dose. Records indicate that the facility logs prescribed medications for residents in care on the centrally stored medication and destruction record to log (LIC 622). However, Daptomycin was not recorded on R1’s LIC 622. Facility administrator stated that since the medication was administered by an external HH nurse rather than facility staff, it had not been recorded on the LIC 622. The facility has been storing the antibiotics for R1 but tracking the medication had not been documented because R1 was receiving HH services. Administrator further stated that R1’s family was expected to refill the antibiotic prescription accordingly and that the HH nurse had been informed about the low supply; however, administrator did not have any supportive documents to provide regarding this agreement. Administrator also could not provide LPAs with HH records pertaining to R1. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff did not ensure that resident’s medication was refilled in a timely manner. Therefore, the above allegation “Staff did not ensure that resident’s medication was refilled in a timely manner” is deemed SUBSTANTIATED at this time. Continued on LIC 9099-C Continued on LIC 9099-C Regarding allegation unlawful eviction. It was alleged that administrator unlawfully evicted R1 by refusing to allow R1 to return to the facility after hospitalization. It was further reported that when R1’s family attempted to arrange R1’s return back to the facility on 04/29/2024, and they were informed that the facility could no longer meet R1’s needs. Information gathered during the course of the investigation reflected that R1 was admitted to the hospital due to the facility’s failure to obtained prescribed medication timely. However, when R1 was ready to be discharged from the hospital, the administrator informed that the facility could no longer accept the resident due to R1 needing a higher level of care. Therefore, R1 was left with no alternative place to go and was presented with only two options, being dropped off at the nearest homeless shelter or to seek accommodation with a family member. Additional information gathered, also reflected that staff did not conduct an initial pre-placement appraisal nor a reappraisal prior to hospital discharge before determining the resident needed a higher level of care. Moreover, R1 was also not issued a proper eviction notice. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was unlawful evicted. Therefore, the above allegation “Unlawful eviction” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.