complaint·May 10, 2024

On 08/10/23 Licensing Program Analyst (LPA) Mario Leon initiated a complaint visit for the allegations listed above. Today’s complaint investigation was greeted by, and conducted with, Veronica Gomez, Administrator. LPA explained the purpose of the visit. The investigation consisted of the following: LPA attempted contact with the reporting party (RP), who was unavailable. LPA toured the facility and interviewed three (3) clients, two (2) staff and one (1) witness. LPA requested facility records and staff records. Allegation(s): Due to staff negligence, resident did not receive medications. Staff are falsifying resident records. The investigation revealed the following: Regarding the allegation "Due to staff negligence, resident did not receive medications,” and “staff are falsifying resident records,” it is being alleged that R1 left the facility on 07/19/23 and staff notated on the EMAR that R1 took R1’s 8:00 AM and 12:00 PM medication. RP stated that during this time, R1 was away from the facility and did not receive medication. Record review reveals that R1 did not take R1’s 8:00 AM nor 12:00 PM medication on 07/19/23. The EMAR revealed that R1 only took 8:00 PM medication on 07/19/23. Interviews conducted reveal: 10 out of 12 staff members indicate that when families or residents provide notice of a facility departure, MedTech will prepare medication and leave at the front desk to ensure that residents do not miss their dose(s). Three (3) out of four (4) resident interviews, including R1, indicate that medication is provided when they need to leave the facility for a great length of time. LPA Leandro’s resident interviews reveal: 5 out of 8 residents, including four (4) from memory care, were unaware of the medication release process. Regarding the allegation “Due to staff negligence, resident did not receive medications," and “staff are falsifying resident records,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for these (2) allegations. Continue to LIC9099-C Allegation(s): Due to staff negligence, resident did not have blood sugar checked. The investigation revealed the following: Regarding the allegation " Due to staff negligence, resident did not have blood sugar checked,” it is being alleged that R1 did not have R1’s blood sugar tested the last two days. RP called on 07/31/23. Record review reveals that R1’s blood sugar was tested on 07/29/23 and 07/30/23. Blood sugar was not tested on 07/31/23. On 08/10/23, LPA Mario Leon interview with License Vocational Nurse (LVN) (S3/W1) indicated that R1 refused to be tested. The facility has a numbering system and S3/W1 was on number 5 and R1 had number 11. S3/W1 informed R1 that S3/W1 was unable to immediately assist R1. Then R1 refused. Based on record review and interview, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Peggy Clark.