complaint·October 9, 2023

Regarding the allegation that the facility allows resident's medication supply to run out: Per staff statements, facility medication technicians and nurses are trained to reorder once-a-day medications 7 days in advance and twice-a-day medications 14 days in advance to ensure medications do not run out. Medication audits are also regularly conducted. LPA interviewed AD and the Wellness Director who denied the allegation and stated there are no issues with medications at the facility. LPA interviewed 10 residents and 3 residents stated they received assistance with medications. LPA reviewed MARs for these 3 residents for the past 3 months and observed that 2 of these residents, Resident #1 (R1) and Resident #2 (R2), had missed doses of medications due to the facility running out of supply, including 6 missed doses of Sertraline HCl Tablet 100 MG, 2 missed doses of Klor-Con 10 Oral Tablet Extended Release 10 MEQ (Potassium Chloride), and 1 missed dose of Furosemide Oral Tablet 20 MG (Furosemide). Per the Mayo Clinic, Sertraline is used to treat depression and other psychiatric disorders and missing several doses of an antidepressant may cause discontinuation syndrome the symptoms of which include agitation, sleep disturbances, dizziness, and flu-like symptoms; Potassium Chloride is used to treat blood pressure issues and a lack of potassium may cause muscle weakness, irregular heartbeat, mood changes, or nausea and vomiting; and Furosemide is used to treat fluid retention and swelling caused by congestive heart failure and other conditions and should only be taken as directed by the patient’s doctor. Regarding the allegation of lack of staffing: It was alleged residents were left in their chairs in the same positions for extended periods, wellness checks are not being conducted, and residents’ food intake is not being monitored properly resulting in weight loss. LPA interviewed AD who denied the allegation and stated that the facility has been using staffing agencies to fill in any staffing gaps since 2020. When interviewed, the Wellness Director denied the allegation and stated that staffing at the facility is based on a system which calculates how many service hours are required daily by the care plans of the residents and determines the number of staff needed. For example, on 08/23/23, the staffing schedule was 3 caregivers and 1 medication technician for the morning shift, 2 caregivers and 1 medication technician for the afternoon shift, and 3 caregivers and 1 medication technician for the overnight shift, with the Wellness Director, Wellness Coordinator, and Residential Care Coordinator also scheduled. Staff interviewed stated that based on their care plans, not all residents receive wellness checks. Residents are able to use their pendant to call for assistance. Residents who have difficulty using the pendant are scheduled for regular wellness checks. LPA reviewed weight records for 10 residents which show that residents’ weight is closely and regularly monitored by the facility and that 2 residents lost enough weight to trigger warnings in the facility system and 1 of these residents has already regained weight. AD stated that AD, the Resident Care Coordinator, and the facility’s nurses conduct twice monthly meetings to discuss resident status and changes and to adjust the residents’ care plan if needed to address issues like weight loss. LPA interviewed 10 residents and none of the residents reported any issues with wellness checks, nutrition, or weight loss. However, 3 residents corroborated that the facility does not have enough staff and that the wait times for assistance after pressing the pendant can be as long as 1 hour and 15 minutes during busy periods. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations of facility allows resident's medication supply to run out and lack of staffing. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that residents are not receiving services paid for: It was alleged residents were not taken out of their rooms for 3 months in 2020 but were paying additional fees to be escorted around the facility. LPA interviewed AD and facility staff who stated that care plans are created based on residents’ needs and, from these care plans, assignment sheets are created which specify what services the residents are to receive and at what frequency. All services are presumed provided unless the care staff reports that the resident refused the service. Refusals are documented in the resident’s progress notes and the facility will address the issue with the resident and their family. LPA interviewed 10 residents and none of these residents corroborated this allegation. Regarding the allegation that lack of care and supervision resulted in a resident's death: Per witness statements, on 05/26/20 Resident #3 (R3) had a pulse oxygen reading of about 95%. R3’s pulse oxygen was not read again until 05/28/20 when R3 called for assistance with complaints of nausea and vomiting at which point their pulse oxygen was checked again and read at 82%. R3 was taken to the hospital where they passed away on 06/01/20. Per staff statements, R3’s primary diagnosis was hypertension with congestive heart failure, R3 was not on hospice, R3’s passing came as a surprise, and R3’s cause of death was respiratory failure related to their congestive heart failure. LPA reviewed R3’s Physician’s Report dated 03/22/18 which states R3’s diagnoses included congestive heart failure, coronary artery disease, and mild cognitive impairment. R3’s Physician’s Report also states that R3 was ambulatory, able to follow instructions, able to communicate needs, able to leave the facility unassisted, able to store and administer their own medications, and had a do-not-resuscitate order but was not on hospice. LPA reviewed Hoag Hospital Irvine Medical Records dated 09/20/23 which state on page 11 that R3 had a history of congestive heart failure, a pacemaker, recurrent pneumonias and bronchitis and that R3 was taken to the hospital on 05/28/20 due to hypoxia after facility staff tested R3’s pulse oxygen at 70%. On pages 17 and 18, the Medical Records indicate that, while having a pulse oxygen of 70%, R3 did not express any shortness of breath and was speaking clear and complete sentences. Per page 35 of the Medical Records, at the hospital R3 stated that, overall, they have been in very good health. However, assessment at the hospital revealed R3 was “profoundly hypoxic” and had “severe sepsis.” On page 47, the Medical Records describe that despite aggressive measures in the Critical Care Unit, R3’s condition deteriorated and R3 and their family decided to start comfort care in lieu of additional aggressive treatment. Per page 65 of the Medical Records, R3 passed away on 06/01/20 at the hospital. The Medical Records do not indicate that hospital staff suspected neglect or lack of care at the facility. The hospital social worker’s assessment on page 61 of the Medical Records states only that R3 lived with their spouse at the facility, had an “independent” level of function, and that the social worker found no “discharge barriers” if R3 were to be returned to the facility. On page 381, the Medical Records indicate that R3 denied having concerns about the facility. No information was obtained indicating that R3 required regular wellness checks or pulse oxygen readings and no reports were received from the hospital, R3’s family, or R3 themselves regarding any concerns about R3’s care at the facility. Regarding the allegation that the facility failed to report an incident as required: It is alleged the facility accepted a resident back from a skilled nursing facility with a diagnosis of Clostridioides Difficile and failed to report it. LPA interviewed AD who denied this allegation. LPA interviewed the Wellness Director who denied this allegation and stated that the facility requires a negative test result or documentation that the infection has colonized before accepting a resident who was diagnosed with Clostridioides Difficile. The Wellness Director compiled a Diagnosis Report from the facility’s electronic medical record system showing all diagnoses of all residents at the facility. LPA reviewed the Diagnosis Report which does not include Clostridioides Difficile. No information was obtained corroborating this allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that residents are not receiving services paid for, lack of care and supervision resulting in resident's death, and failure to report incident as required occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that the facility falsifies records: It was alleged the facility cannot accept residents with dementia and the facility ensures none of the residents have a dementia diagnosis by paying the 2 pre-contracted doctors $250 to falsely state that residents do not have dementia on their Physician’s Reports. LPA interviewed AD and the Wellness Director who denied the allegation and stated physician’s reports are completed by residents’ primary care physicians because they have history with these residents. LPA reviewed Physician’s Reports for 13 residents which showed that they were completed by 12 different doctors (2 residents who are related used the same doctor). LPA interviewed 10 residents none of whom provided information corroborating this allegation. AD stated the facility does not accept new residents with dementia and provided an email dated 07/10/23 in which she rejected a prospective resident for having a dementia diagnosis and referred them to facilities with memory care units. AD also stated that current residents who develop dementia are allowed to age in place and continue to live at the facility as long as their assessments indicate their needs can be met at the facility. LPA reviewed the facility’s file and confirmed that the facility is able to accept and retain residents with dementia, meaning the alleged falsification of Physician’s Reports would not even be necessary. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.