Inspector’s narrative
What the inspector wrote
Investigation Revealed the Following:
Allegation:
Resident not assisted with medications as prescribed.
The details of the complaint alleged that facility did not follow (R#1)’s prescribed medications order.
On May 29, 2025, at approximately 3:00 PM, during a records review, LPA Iniguez observed Resident #1's Medication Administration Records (MARs) for April 2025. LPA Iniguez noted that the medication order for Ferrous Sulfate 325 MG Tablet prescribed one tablet to be taken by mouth once daily on Mondays, Wednesdays, and Fridays until April 23, 2025, when the physician discontinued it. However, facility staff documented on the MARs that they administered the medication to (R#1) for nine consecutive days, from April 14, 2025 (Monday) to April 22, 2025 (Tuesday). LPA Iniguez found that facility staff did not follow the prescribed medication order for (R #1). Moreover, LPA Iniguez reviewed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated: 8/19/24, it is noted that (R#1) is not able to administer their own prescribed medications.
On May 29, 2025, at approximately 10:00 AM, during an interview with the Administrator (A#1), she stated that there is an ongoing investigation to determine why the facility did not follow up on the order.
On May 29, 2025, at approximately 2:00 PM, interviews with facility staff (S#1-S#3) revealed that all (3) staff members did not follow up on (R#1)’s medication order prescribed by their physician.
Evaluation Report continues LIC 9099-C
During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.
Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be
SUBSTANTIATED.
California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).
An exit interview was conducted, and a copy of the Complaint Report was given to Monique Avila/Wellness Director.
Investigation Revealed the Following:
Allegation:
Facility allowed resident t to be restrained.
The details of the complaint alleged that facility did not follow (R#1)’s doctors’ orders on restrains.
On May 29, 2025, at approximately 3:00 PM, during a records review, LPA Iniguez examined the facility file for (R#1). Within this file, LPA Iniguez found copies of Nurse Practitioner (NP) orders related to restraints. The first order dated January 9, 2025, states that it is permissible for (R#1)’s family to apply a nighttime restraint, provided by (R#1)’s family. The family assumes responsibility for any adverse occurrences and risks discussed with the care facility. Additionally, LPA Iniguez found another NP restraint order dated February 7, 2025, which instructs to discontinue all restraints that had been placed on (R#1) by the family.
On May 29, 2025, at approximately 10:00 a.m., during an interview with the Administrator (A#1), she stated that the facility always follows the orders of the residents’ doctors or Nurse Practitioners. In addition, (A#1) stated that yes, we follow the Nurse Practitioner (NP) order for restraints regarding (R#1). The family is supposed to put the restraints on at night, and we will remove them in the morning. The order was discontinued by the (NP) after a month.
On May 29, 2025, at approximately 3:00 PM, during interviews with residents (R#1-R#7), (7) out of (7) stated that they received their medical orders from their physician here at the facility. Additionally, (7) out of (7) residents in care stated that they believe the facility staff follow the orders as prescribed by their physician.
On May 29, 2025, at approximately 1:00 PM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that (R#1) had a prescribed order for restrains. They followed the order as noted by the Nurse Practitioner (NP) until it was discontinued on 2/7/25.
Evaluation Report continues LIC 9099-C
During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).
Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be
UNSUBSTANTIATED.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted, and a copy of the Complaint Report was given to Monique Avila/Wellness Director.
