complaint·April 16, 2026

When interviewed, R1 stated they moved into the facility in April 2025, initially handled their own medications, but that they were later reassessed to require medication management by the facility. Review of R1’s Personal Service Plan dated April 25, 2025, confirms that R1 initially handled their own medications and review of R1’s Personal Service Plan dated July 3, 2025, confirms the facility began managing R1’s medications on July 3, 2025. Per R1’s Home Health Medical Records, on May 28, 2025, R1 was prescribed Furosemide 40MG for congestive heart failure with instructions to take one and a half tablets daily and if there is a weight gain of two pounds or greater overnight, 5 pounds over one week, or if R1 experiences swelling or shortness of breath, then to take an additional one and a half tablets for one to three days then return to the previous dose. R1’s Home Health Medical Records also indicate that on July 1, 2025, R1’s doctor issued a new order for R1 to take two tablets of Furosemide 40MG daily on July 3, 4, and 5, 2025 for fluid retention. Interviews with AD and two facility staff revealed that there was confusion with R1’s new order for Furosemide, which was not properly clarified, resulting in a medication error by facility staff where R1 did not receive any Furosemide after the new order ended on July 5, 2025, when R1 should have returned to their previously prescribed dose. R1’s Medication Administration Records do not indicate that Furosemide was ever given to R1, except on July 3, 4, and 5, 2025, where on July 3, 2025, R1 was given two tablets as prescribed, but on July 4 and 5, 2025, R1 was actually given six tablets each day which is triple the prescribed dose. Per R1’s Garden Grove Hospital Medical Records, on July 8, 2025, R1’s nurse checked on R1 at the facility and noted R1 to be hypoxic, R1 was taken to the emergency room and diagnosed with pulmonary hypertension, hypotension which is likely caused by the pulmonary hypertension, dyspnea, urinary retention, pulmonary edema, and a urinary tract infection, as well as community acquired pneumonia and hyponatremia, R1 was hospitalized, and R1 was discharged to Kaiser Permanente hospital on July 10, 2025. Per R1’s Kaiser Permanente Medical Records, R1 was admitted on July 10, 2025, for acute on chronic hypoxemic respiratory failure, R1’s diagnoses included pulmonary hypertension, interstitial lung disease, cor pulmonale, coronary artery disease without angina, presence of stent diastolic heart failure, chronic hypoxemic respiratory failure, bronchiectasis, and R1 was discharged back to the facility on July 13, 2025. Per a witness from Kaiser Permanente, on July 7, 2025, R1’s home health nurse visited R1 at the facility and discovered that R1 had not received their prescribed dose of Furosemide. This witness also confirmed that R1’s doctor at Kaiser Permanente hospital determined that R1 not receiving their Furosemide as prescribed caused their hypotension and fluid on the lungs. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.