complaint·April 3, 2026

It was alleged that R1 received IV infusions with an IV bag that had a partially peeling or missing label, R2 received IV infusions with an IV bag that had another resident’s name on it, and the facility had no doctor’s orders for the IV infusions. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who admitted the allegation, stating that on March 16, 2026, R1 and R2 were administered IV infusions due to weakness and not eating, the IV infusions were ordered by the residents’ nurse practitioner verbally but a written order was not received until the nurse practitioner arrived at the facility on March 18, 2026, and that the IV bags given to these residents were from the facility’s stock and were not delivered to the facility for these residents. LPA reviewed R1’s IV Order dated March 13, 2026, and R2’s IV Order dated March 16, 2026, which per AD were written on March 18, 2026, but given verbally on March 16, 2026, and noted they are for “IV 05 ½ NS”. LPA observed six IV bags at the facility, none of which were labeled for R1 or R2. Two bags were labeled for Resident #3 (R3), who per AD is no longer a resident of the facility and moved out on October 31, 2025. All six IV bags are labeled as “Sodium Chloride 0.9% Solution”. However, the labels of the bags actually administered to R1 and R2 are no longer available. AD stated they are not knowledgeable about IV bags, but the nurse who administered them would have handled it. LPA attempted to interview the nurse that administered the IVs to R1 and R2, but was unsuccessful. LPA interviewed two staff who were unable to provide information regarding this allegation. LPA reviewed the Medication Administration Records for R1 and R2, which did not contain orders for IV infusions or document the IV infusions administered. Although the facility eventually received written doctor’s orders documenting that IV infusions were ordered for R1 and R2, R1 and R2 received IV bags that were delivered to the facility other residents and it is unknown if they received the correct IV bags as ordered by their doctor. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that Resident #1 (R1) and Resident #2 (R2) received IV infusions at the facility without staff or licensed supervision present. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation, stating that the IV infusions were administered by the facility’s on-call registered nurse. LPA interviewed two staff who were unable to provide additional information. When interviewed, R2 was unable to provide information regarding the allegation, but R1 stated a nurse administered their IV and staff stayed with them while it was in place. LPA attempted to interview the nurse who administered the IV, but was unsuccessful. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above 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, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.