Complaint·April 21, 2025

Continued from LIC9099 LPA conducted interviews with witnesses and facility staff. Interviews conducted provided conflicting information. Interview conducted with W1 stated that facility staff would either forget to put R1’s hearing aids on in the morning or forget to take them off at night, resulting in R1’s hearing aids getting lost and needing replacement. W1 also stated that facility staff did not receive training on how to insert R1’s hearing aids and that the hearing aids were rechargeable and did not use batteries. Interview conducted with Memory Care Director stated that facility staff were taught how to insert R1’s hearing aids by R1’s family as the insertion is different compared to other hearing aid models. Interview also stated that R1’s hearing aids are to be inserted by the facility medication technicians, and they receive a notification from facility staff when R1’s hearing aid filters have been changed. Interview conducted with facility staff stated that they received training on how to insert R1’s hearing aids, that R1’s hearing aids are rechargeable, and that R1’s hearing aid filters are changed weekly. Per interview conducted, R1’s hearing aids are charged in the medication room and only medication technicians are to insert them. Review of facility documents indicated that facility staff were documenting when R1’s hearing aid filters were changed and when R1 would refuse to have their hearing aids put in. Based on interviews conducted and record review, this allegation is Unsubstantiated . A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents. Continued from LIC9099 Review of R1’s physician orders from 08/08/2024 showed the following instructions for R1’s routine inhaler and eyedrops: · Alvesco 160MCG Inhaler (60); Inhale 2 puffs by mouth daily for asthma prevention and control, rinse mouth well after use · Dorzolamide HCL 2% Eye Drops; Instill 1 drop in both eyes twice daily for glaucoma · Latanoprost 0.005% Eye Drops; Instill 1 drop in both eyes every evening LPA conducted interviews with witnesses and facility staff. 3 of 4 interviews stated that they had heard of medication being documented as given or administered when the medication was unavailable or not in the cart. Interview conducted with facility staff stated that they have seen medication in resident rooms that have not been given. Review of Facility documentation showed that a medication training was conducted by the Health and Wellness Director in February 2025. Additional documentation showed that another training was conducted by the Regional Health and Wellness Director on the topics of medication refills, proper documentation, and medication administration in March 2025. Email correspondence and photographs provided to the LPA revealed that a medication audit was conducted on 02/21/2025 where it was found that R1’s medications were not given as prescribed. Interviews conducted with Regional Health and Wellness Director and Memory Care Director confirmed that a medication audit for R1 took place where medication errors were found such as administering expired medications. Based on interviews conducted, record review, and observations made, these allegations are Substantiated . A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty in the total amount of $250.00 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. Deficiency last cited on 12/05/2024. (See LIC421FC)** Exit interview conducted. Copy of report, LIC421FC (Civil Penalty), Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.