complaint·June 19, 2023

The investigation revealed the following: Regarding the above allegations- Resident had access to medications resulting in overdose: It is alleged that R1 had access to medications which resulted in R1 overdosing and being administered Narcan in the ER. R1 was admitted into the facility on 03/20/2020. Physician’s Report dated 2/25/2020 revealed R1 required medication management. Four (4) out of the four (4) staff interviewed deny the above allegation. During physical plant tour of facility on 03/21/23, LPA Ramirez observed centrally stored medications cabinet to contain a padlock and was inaccessible to residents in care. LPA reviewed R1’s Centrally Stored Medication List (LIC 622). Per facility staff, R1 was administered medications as directed by physician and according to label on all prescriptions. LPA Ramirez could not locate any other pertinent documents that suggest facility staff did not adhere to directions on medications list. On 04/05/23, LPA Ramirez sent R1’s LAB results and discharge documents dated 01/07/21 to this departments Program Clinical Consultant. Due to limited information provided at that time, consultants were not able to provide complete interpretation and conclusion of results. Resident did not receive timely medical attention: It is alleged that R1 did not receive medical attention in a timely manner. Four (4) out of four (4) staff deny this allegation. LPA Ramirez reviewed facility staffing notes dated 01/07/21, 01/25/21 and 01/27/21, which documented R1 requiring medical treatment and intervention/solution. LPA Ramirez reviewed medical treatment and discharge documents dated 01/07/21 for R1. One (1) resident interviewed denied this allegation. Resident's medications were mismanaged: It is alleged that R1’s medications were mismanaged. LPA Ramirez reviewed R1’s Centrally Stored Medications list. LPA could not locate any discrepancies upon review of medication list. Four (4) out of four (4) staff deny this allegation. One (1) resident interviewed denied this allegation. LPA Ramirez could not locate any other pertinent documents that suggest facility staff were mismanaging R1’s medications. Resident's care needs were not being met: It is alleged that R1’s care needs were not being met. Four (4) out of four (4) staff deny this allegation. One (1) resident interviewed denied this allegation. LPA Ramirez reviewed staff progress notes that revealed staff administered care to R1 on daily basis. Although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Toby Miclat and a copy of this report was provided via email due to printer problems.