complaint·February 19, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff mismanaged resident's medication. The complaint detailed allegation of mismanagement regarding Resident #1's (R1's) medications by the staff. It has been reported that the facility issued pain medications and antifungal cream that were not authorized by R1's primary physician. Additionally, the facility authorized refills for medications from R1's former primary physician instead of the current physician. On November 2, 2024, R1 was admitted to the hospital, where it became evident that the facility had failed to administer necessary diabetic medications. This oversight raised significant concerns, especially since R1's blood glucose levels were not being consistently monitored, which is critical for effective diabetes management. On November 2, 2024, R1 was admitted to Los Alamitos Medical Center for altered mental status caused by low blood sugar. An Unusual Incident Report from November 6, 2024, noted that R1 was feeling lightheaded in the dining area at 8:30 PM, just moments before the observation. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 through Staff #5). All of them acknowledged that Resident #1 (R1) had been hospitalized due to general weakness. Staff #2 (S2) claimed that no one from the hospital inquired about R1's diabetic diagnosis. S2 was uncertain whether there had been any miscommunication regarding R1's prescribed medications with the pharmacy. Staff members S2 through S5 were aware that R1 had been receiving diabetic medications daily since their admission to the facility. They indicated that R1 was only receiving medications prescribed by R1's physician. Staff members S3 through S5 stated that the medication technicians were responsible for monitoring R1's blood glucose levels and that there should be a chart log documenting the daily results. However, Staff #1 (S1) claimed that R1’s service plan did not include care staff to monitor R1’s blood glucose levels. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 through Witness #5) regarding the allegation. One out of the five witnesses reported some discrepancies with medications being refilled, discontinued, or continued to be administered. Evaluation Report continues LIC 9099-C INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff did not safeguard resident’s personal items. The complaint alleged that the facility failed to safeguard the personal items of Resident #1 (R1). It was reported that R1's tooth retainer and hearing aids went missing, for which the facility has since provided reimbursement. However, R1's wheelchair, which was labeled with R1's name, also went missing and was replaced with a wheelchair that did not belong to R1. No further details were provided about this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed five staff members, identified as Staff #1 through Staff #5, regarding the allegation. Staff #1 and Staff #2 (S1 and S2) confirmed that the facility reimbursed R1 for the retainer and hearing aids. Staff #2, along with Staff #3 to Staff #5 (S3 to S5), claimed they had never seen R1 with a personalized manual wheelchair. Rather, they mentioned observing R1 with multiple wheelchairs in R1's room. Staff #5 described R1 using a walker-wheelchair combination, while Staff #2 to Staff #4 described a regular manual wheelchair. Staff #2 stated that all personal items belonging to R1 were documented on a Facility Resident Inventory List and disputed the existence of a personalized wheelchair for R1, asserting that it was never listed on R1's inventory and should have been identified by a serial number. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives, identified as Witness #1 through Witness #5, regarding the allegation. All five witnesses (W1 to W5) could not corroborate the claim, stating personal items were never reported missing or lost. They confirmed that residents completed an individual property and valuables inventory list upon admission. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents, identified as Resident #2 through Resident #6, regarding the allegation. All five residents indicated that they had not experienced any missing or lost items while in care at this facility. A review of R1's service records included an Inventory of Personal Effects dated January 25, 2019, which listed 19 items, including a walker wheelchair, but did not provide a serial number for description. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #2: Staff did not ensure that resident's dental hygiene was met. The complaint stated that the facility staff did not ensure that Resident #1 (R1) received adequate dental hygiene. It was reported that R1 had not received brushing and cleaning for four or five months. Additionally, it was noted that the staff was unaware that R1 had a partial front tooth retainer, which had not been removed for cleaning. No further details were provided regarding this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed four staff members (Staff #2 to Staff #5) regarding the allegation. They indicated that R1 was assisted daily with dental hygiene. Staff members S3 and S4, who were the primary caregivers for R1, explained that R1 preferred to perform hygiene care independently but received assistance from staff through verbal cues or contact guard support. Staff members (S2 to S5) were unaware that R1 had partial retainers, only learning of this information years later. (S2) reported that R1 had been receiving home health services from August to November 2024, with weekly visits from home health staff for healthcare services. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 to Witness #5) regarding the allegation. All five witnesses stated they could not support the claim, asserting that residents had never faced any oral hygiene issues or concerns. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents (Resident #2 to Resident #6) about the allegation. All five residents indicated that they had not experienced any issues with their oral hygiene care. Three out of five stated they received daily assistance from care staff, while the other two preferred to manage their oral hygiene independently. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus, identified as Witness #6. They explained that R1 was receiving home health care services with weekly visits from a Licensed Vocational Nurse (LVN), although these visits did not include grooming or dental care. A review of R1's Physician's Report (LIC 602A) dated January 24, 2019; January 11, 2020; January 27, 2021; and January 19, 2022; as well as the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019, revealed that R1 required assistance with personal hygiene. Medical assessment reports indicated that R1 did not have dentures or retainers until 2022. The facility decisively failed to maintain progress notes for Resident #1, resulting in a significant gap in their care documentation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #3: Staff did not ensure that resident was adequately fed. The complaint states that the staff did not ensure that Resident #1 (R1) is adequately fed. It is reported that R1 lacked nutrition due to not eating enough, which is attributed to R1's recent hospitalization. Further reports indicated that after hospitalization, the physician ordered R1 to be given Ensure drink supplement twice daily. However, an inventory surplus showed that this was not carried out according to the doctor's orders. Los Alamitos Medical Center Medical Records indicated that on November 2, 2024, R1 was hospitalized with altered mental status due to hypoglycemia. An Unusual Incident Report dated November 6, 2024, noted that R1 was observed at 8:30 PM on November 2, 2024, in the dining area, feeling lightheaded just minutes before. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 - Staff #5). None of them could corroborate the complaint. They stated that R1 was on a mechanical soft diet and received three meals and snacks in between. According to Staff #1 to Staff #5, the nutritional drink Ensure was provided to R1 twice daily, as prescribed by the physician after hospitalization. Staff #2 reported that R1 was under home health services, receiving weekly visits from a Licensed Vocational Nurse (LVN), and there were no concerns regarding R1's nutrition. Staff #3 and Staff #4 indicated that the meals served to residents meet health standards, are of good quality, and provide adequate portions. They further noted that the facility offers meal substitutes and can accommodate residents with special dietary restrictions. They observed that R1 was a "light eater" who consumed smaller portions of food. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 – Witness #5) regarding the allegation. All five witnesses attested that the residents enjoyed an ample selection of nutritious meals that fully met their dietary requirements. They reported no concerns whatsoever regarding the quality or appropriateness of the food provided. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 - Resident #6) about the allegation. Evaluation Report continues LIC 9099-C They expressed that they had no issues with the meals provided, stating that the portions were sufficient and that there was no shortage of food, including ample snacks. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). The witness confirmed that there were no notable medical concerns regarding R1's nutritional status. (W6) elaborated that R1 was currently taking a variety of multivitamins, along with prescribed medications, which could potentially diminish appetite. The Department reviewed R1's Physician's Report (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022; the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019. These documents revealed that R1 can self-feed and is on a mechanical soft diet. Records from Home Health Plus Services dated August 13, 2024, through November 2, 2024, showed no observations of R1 being undernourished. R1 is prescribed 18 medications and nine out of 18 had side effects for causes of loss appetite (ref: National Institute of Health). Based on the gathered information, there is insufficient evidence to support the stated allegation. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Marcus Falanai, and copies of the reports were provided. All five witnesses concurred that the facility faced significant communication challenges with the authorized parties involved. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 through Resident #6) about the same allegation. The residents collectively stated that they had no issues with their medications and that medications were being administered in a timely manner as prescribed. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). This witness indicated that the LVN nurse was aware of Resident #1's prescribed medications and followed the physician's orders. Witness #6 stated that there were no issues with the facility's administration of medications and that the care staff was monitoring Resident #1’s glucose levels. According to this witness, the LVN nurse it was not needed to monitor during visits since the facility staff had already completed the necessary procedures. An examination of R1's medical documentation, including the Physician's Reports (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022, along with the Facility Service Plan dated November 6, 2024, and Preplacement Appraisal Information from January 25, 2019, was conducted. Additional records from Los Alamitos Medical Center covering the period from November 2, 2024, to November 5, 2024, were also reviewed. Noteworthy documents included an Incident Report LIC 624 dated November 6, 2024, Physicians’ Medication Orders spanning from January 26, 2019, to December 2, 2021, a Medication Administration Record from January 26, 2019, to March 1, 2019, and further Physicians’ Medication Orders dated January 17, 2024, along with the Residential Admission Agreement dated January 25, 2019. The analysis revealed that R1 is diagnosed with a range of diabetic health issues, necessitating careful management. Since admission in 2019, R1 has been consistently prescribed diabetic medications, specifically "Glipizide 5mg & 10mg," to be taken twice daily. However, it was concerning to note that the service care plan did not incorporate any monitoring for blood glucose levels, which is critical for effective diabetes management. A significant deficiency in record-keeping was identified, as vital Medication Administration Records (MAR) were absent for the entire duration from 2020 through 2024. Evaluation Report continues LIC 9099-C Furthermore, R1 had been prescribed PRN (as needed) medications, yet there were no accompanying (MAR) Physician Medication Orders recorded for the years 2022 and 2023. There were no detailed charts available to monitor the ups and downs of blood sugar levels, which raises significant concerns about proper care. Furthermore, the absence of staff notes, or progress reports left important gaps in R1’s care documentation, making it difficult to understand their health changes over time. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on observations, interviews, and record reviews, there is substantial evidence indicating that "Neglect and Lack of Care and Supervision" has been substantiated. This finding is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, as noted on the attached LIC 9099-D. An exit interview was conducted with Marcus Falanai, the Resident Care Coordinator, during which a hard copy of the report and information on appeal rights was provided.