complaint·February 7, 2025

The investigation revealed the following: Regarding allegation(s): Staff did not follow doctor's orders for resident's medication. It is alleged staff did not administer R5 morphine according to R5’s physician orders. R5 was admitted into the facility on 12/29/2024. During record review, LPA Ramirez observed a physician’s order for PRN (as needed) medication of morphine sulfate powder 100/5ML-give 0.25 milliliter for pain every 4 hours, with a start date of 12/30/2024. On 01/05/2025, R5’s physician ordered R5’s PRN of morphine sulfate powder 100/5ML- 0.25 milliliter for pain every 4 hours to change to every 2 hours-administer 0.5ML (10mg) and is now to be administered as a scheduled medication. Review of R5’s MAR for 12/30/2024 through 1/4/2025, revealed staff administered morphine sulfate as a PRN, per R5’s physician orders. Review of R5’s MAR dated 1/5/2025 through 1/6/2025, revealed staff administered morphine sulfate as a scheduled medication, per R5’s physician order. Three (3) out of the three (3) staff interviewed denied this allegation. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff did not provide medical assistance to resident. It is alleged staff did not provide R5 with first aid to a wound on R5’s arm. R5 began receiving hospice care on 12/29/2024. Three (3) out of the three (3) staff interviewed denied this allegation. Staff interviews revealed, on 1/3/2025, staff#1 (S1) saw 2 drops of dried blood on the left edge sleeve of R5’s white tee shirt. S1 checked R5’s left arm and saw a small scratch, no larger than a quarter on R5’s lower arm. S1 revealed the scratch was not bleeding at the time and did appear to need first aid. S1 revealed later that day R5’s responsible party visited R5 and pointed out the dried blood drops on R5’s shirt. S1 advised R5’s responsible party of earlier observation. S1 stated “Hospice was on their way to assess R5 and I asked them to look at R5’s arm, the nurse said it appeared like a small scratch.” LPA Ramirez reviewed hospice care notes dated 1/3/2025 and 1/5/2025 and did not observe hospice care staff document any new injuries to R5 or R5 requiring wound care during visits. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. SEE 9099-C Staff withheld resident's hearing aids. It is alleged staff withheld R5’s hearing aids. Three (3) out of the three (3) staff interviewed denied this allegation. Four (4) out of the four (4) residents interview denied this allegation. R5 is not available for an interview. LPA Ramirez contacted R5’s responsible party via phone but, R5’s responsible party was unavailable for an interview. Staff interviews revealed, R5 was able to remove their own hearing aids and would remove them before bed so staff could charge them. Staff revealed R5 would sometimes request to have staff remove R5’s hearing aids. Although staff interviews revealed R5 had hearing aids, LPA Ramirez observed Client/Resident Personal Property and Valuables (LIC 621) form; section B- Personal property/valuables removed- indicating hearing aids, glasses and a wedding band were removed by R5’s responsible party on 12/29/2024 and was signed by R5’s responsible party. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No violations were cited during this visit. Exit interview was conducted. A copy of this report was provided.