complaint·August 7, 2025

R1 only received one dosage of her Prednisone 20 MG tablet medication since she was hospitalized on May 16, 2025, so there should be four remaining tablets for R1’s Prednisone 20 MG tablet medication. However, per the facility’s medication release form dated May 20, 2025, which was provided to R1’s family, there were only two tablets remaining for R1’s Prednisone 20 MG tablet medication. Therefore, a medication occurred on May 16, 2025, in which R1 received double her dosage for her Prednisone 20 MG tablet medication. Furthermore, LPA reviewed an Internal Occurrence Report from the facility dated May 2, 2025. The Internal Occurrence Report describes how a facility staff mismanaged R1’s Ropinirole 3 MG tablet medication by giving R1 triple her prescribed dosage. Five out of six staff interviews conducted with staff that assist residents with medication confirmed a medication error occurred on May 2, 2025, in which R1 received triple her prescribed dosage for her Ropinirole 3 MG tablet medication. The facility’s Licensed Vocational Nurse (LVN) who was on duty on May 2, 2025, then assessed R1 after the medication error and did not note any adverse reactions. Facility staff then contacted R1’s Primary Care Physician (PCP) who advised the facility that R1 could remain in the community since R1 did not have any adverse reactions. Facility staff then continued to monitor R1s condition by monitoring R1’s blood pressure, heart rate, respiration, and temperature. R1’s family was also informed of the medication error. Based on interviews conducted and the evidence gathered, the Department obtained sufficient evidence to substantiate the allegation that staff mismanaged residents’ medication. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED . See LIC9099D for the deficiency cited per Title 22 Division 6 of the California Code of Regulations. The investigation revealed the following: It was alleged that staff did not assist residents with care in a timely manner. LPA reviewed the call button response times dated March 8, 2025, to May 16, 2025, for R1. Per the call button response times, LPA observed that there were numerous occasions in which R1 had to wait extended periods of time to be assisted by facility staff after she pressed her call button. CONTINUED ON LIC9099-C For example, on March 8, 2025, it took the facility staff 47 minutes to respond to R1 after she pressed her call button. On March 17, 2025, it took the facility staff 62 minutes to respond to R1 after she pressed her call button. On March 21, 2025, it took the facility staff 61 minutes to respond to R1 after she pressed her call button. On April 4, 2025, it took the facility staff 42 minutes to respond to R1 after she pressed her call button. Additionally, on April 29, 2025, it took the facility staff 47 minutes to respond to R1 after she pressed her call buttons. LPA also conducted six staff interviews with staff who are responsible for responding to residents when they press call buttons. Four out of the six staff interviews conducted stated that there have been days when residents would have to wait extended periods of time to be assisted after pressing their call buttons due to staffing issues. LPA reviewed the staffing schedules for the months of March 2025, and April 2025, and determined that there were insufficient staff present on the days R1 had to wait extended periods of time to be assisted. Based on interviews conducted and the evidence gathered, the Department obtained sufficient evidence to substantiate the allegation that staff did not assist residents with care in a timely manner. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099D for the deficiency cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Director of Health and Wellness Lori Salas, and the report was explained. A copy of the report and Appeal Rights were also provided. LPA reviewed the Death Report dated May 21, 2025, which states that R1 was transported to the hospital after experiencing left arm pain and vomiting. The Death Report further states that R1 passed away at the hospital. LPA reviewed the medical records from Providence Mission Hospital dated May 16, 2025, to May 17, 2025, for R1. Per the medical records, R1 was admitted to Providence Mission Hospital on May 16, 2025, with is diagnoses of intermittent complete heart block, hiatal hernia, and acute hypoxemic respiratory failure. LPA reviewed the County of Orange Health Care Agency certificate of death for R1. Per the certificate of death, R1’s cause of death was cardiac arrest, respiratory failure, and aspiration pneumonia. LPA reviewed the Medication Administration Record (MAR) dated May 1, 2025, to May 16, 2025. LPA observed there was a medication error on R1’s prednisone 20 MG tablet medication in which R1 received double her prescribed dosage on May 16, 2025. However, per the review of the medical records and the certificate of death, the medication error was not listed as the immediate cause of death, or the underlying cause of death, for R1. Based on the evidence gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. The investigation revealed the following: It was alleged that staff did not answer facility telephone. During the course of the investigation, LPA was informed that the facility has multiple telephone numbers that are all forwarded to the facility’s 24-hour line. These telephone numbers include (949) 227-3185, (949) 216-5406, (949) 236-6135 and residents’ families can call these telephone numbers to reach the facility staff during, and after normal business hours. On July 17, 2025, at 11:30 PM, LPA called the telephone number (949) 227-3185. Facility staff answered the telephone after 23 seconds. On July 18, 2025, at 6:55 AM, LPA called the telephone number (949) 227-3185. Facility staff answered the telephone after 13 seconds. CONTINUED ON LIC9099-C Based on the evidence gathered during this investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Director of Health and Wellness Lori Salas, and a copy of the report was provided. Six out of six resident interviews conducted also confirmed that they currently have had access to hot water for personal care. LPA tested the hot water temperature in seven resident bathrooms, including R1’s former unit, which tested between 115.1 to 116.7 degrees Fahrenheit. LPA reviewed the facility’s hot water temperature logs, maintenance notes, conducted an interview with the maintenance personnel, and was informed there was an issue with the hot water temperature on May 5, 2025. However, LPA was informed that maintenance personnel discovered what the issue was and were able to fix it on the same day. The maintenance personnel reported that no further issues with the hot water temperature have occurred at the facility since then. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Director of Health and Wellness Lori Salas, and a copy of the report was provided.