complaint·April 12, 2022

Regarding Allegation #3 : this investigation revealed that the medication “ Oxycodone ” is a PRN and is to be administered “three (3) times a day as needed” to the resident. A review of the resident’s medication administration record (MAR) for the month of January 2022 did not document that the resident was administered the medication (Oxycodone) on 01/13/22, 01/18/22, 01/20/22, 01/24/22, 01/25/22, 01/29/22, 01/31/22 as stated by the complainant. The medication (patch) “ Fentanyl ” is to be administered every 72 hours. A review of the resident’s MAR for month of January 2022 documented Resident #1 was not administered the medication patch (Fentanyl) at 8:00 a.m. on 01/04/22, 01/07/22, 01/10/22, 01/13/22, 01/19/22, 01/25/22, 01/28/22, 01/31/22. Upon conducting a medication review, the medication (Fentanyl) should be administered at “bedtime” not at 8:00 a.m. (photo). The medication “ Methadone ” is to be administered “every six (6) hours”. A review of the resident’s MAR for the month of January 2022 documented Resident #1 was not administered the medication (Methadone) on 01/01/22, 01/02/22, 01/08/22, 01/15/22, 01/16/22, 01/22/22, 01/23/22, 01/29/22, 01/30/22 every six (6) hours. In addition, the medication (Methadone) was not administered on 01/03/22, 01/04/22, 01/09/22, 01/10/22, 01/11/22, 01/17/22, 01/18/22, 01/24/22, 01/25/22, 01/31/22 at 6:00 p.m. A review of the resident’s MAR for January 2022 documents the resident was administered the medication “ Gabapentin ” on 01/31/22 at 8:00 a.m. and 12:00 p.m. The medication “ Tramadol ” was not administered to Resident #1 on 01/29/22 at 12:00 p.m. or 2:00 p.m. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority replied that they have not received complaints from residents regarding not receiving their prescribed medication(s) by the med techs. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8); and, the majority reported that they have not had any areas of concern with their prescribed medications being administered by the med techs. Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has been met; therefore, the allegation of MEDICATION: Resident does not receive medication as prescribed is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies were observed and citations issued (ref. LIC 9099D). An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator (Peggy Clark). Regarding Allegation #1 : this investigation revealed in Resident #1’s administrative file, documentation received by the resident as follows: Facility letter (dated 12/01/21) regarding “ Rent Increase Notice ” effective 01/01/2022; Notice from Archangel Care Coordination Agency regarding new SSI/SSP rates for non-medical out-of-home care (NMOHC), effective 01/01/22; Informational Sheet from Libertana Home Health regarding new SSI/SSP rates for 2022. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority indicated that they had not received complaints from residents regarding them not receiving a notice of rent increase, effective 01/01/22. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8) who replied that over the years, the facility has increased rent rates on an annual basis; and, they did receive their letter regarding the rent increase, effective 01/01/22. Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Facility did not provide proper notification of rate increase is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed that Resident #1’s USPS Mail - upon receipt from the USPS mail carrier, the mail is sorted and distributed to residents accordingly. LPA/RA observed the facility’s process upon receiving the mail delivery (approx) 11:30 a.m. is sorted by the receptionist and distributed by the caregivers to the residents by room number. LPA/RA Ceniceros interviewed eight (8) facility staff members (S1-S8); and, the majority stated that they had not received complaints from residents regarding their mail having been opened by facility staff. LPA/RA Ceniceros interviewed eight (8) residents (R1-R8) who replied that their daily mail has not ever been opened by facility staff. Based on interviews, observations, evidence gathered, information, and documentation obtained and reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff open resident’s mail is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to Administrator (Peggy Clark).