complaint·May 18, 2025

R1 paid approximately $280 a day for the private aide. It was reported that R1 also received a billed from the facility for two months rent which included charges for additional services. According to R1 the additional services facility was charging was provided by the private aides which was already paid. It was confirmed through interviews and records review that R1 was charged/billed in error for additional services not rendered. R1 and ED confirmed that a credit was issued for the additional service charges. Based on the information obtained through record review and interviews; the allegations “Facility is charging resident for services not received”, is deemed substantiated at this time. Regarding allegation: Staff did not accord resident privacy: Information was provided that while R1 was on an outing, facility staff entered R1's room and took all medications (OTC, prescribed, and vitamins). To investigate this allegation, LPA conducted interview with R1, staff and reviewed records. Interviews revealed that R1 was hospitalized temporarily in 9/2024 due to a medication error. Records reviewed revealed that R1 was able to store and handle own medications. Staff confirmed that they entered R1’s room when R1 was not home and removed all medications. Staff expressed that for safety reasons it was the only solution at the time as a result of R1 mismanaging medication. Based on the information obtained through record review and interviews; the allegation “Staff did not accord resident privacy”, is deemed substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are cited (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. Information was received that on 10/27/2024 the facility ran out of R1's prescription for Percocet, which R1 had to take daily for pain. Apparently, staff had not re-ordered the medication on time and R1 had to go all day without pain medication because the pharmacy uses a system called "Guardian" and the medications are only delivered in the evening. Interview with staff and records review confirmed that the medication in question was a narcotic and needed an order form the doctor for staff to send out for refill. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure that resident is provided their medication(s) as prescribed” is deemed unsubstantiated at this time. Regarding allegation: Staff are not following resident's physician order: Information was received that facility refused to follow order from R1’s primary care physician stating that R1 can store and administer OTC and vitamins. Staff interviewed stated that the physician order was received in the evening on 10/21/2024, however a new physician report was required therefore until that was completed and returned medication was held. Staff reported that the OTC and vitamins was returned to R1 when the physician report was completed by the primary doctor in 11/2024. Random residents interviewed reported no issues with facility medication management. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not following resident's physician order” is deemed unsubstantiated at this time. Exit interview held. Copy of the report provided.