complaint·May 27, 2022

Interview with staff member (S1), conducted on 11/10/2021, indicated that paramedics arrived at the facility to assist with transferring resident (R1) to the hospital on 11/4/2021. S1 stated that they gave paramedics R1's file. However, as S1 was making copies of documents from R1's file, they noticed that the files copied were not for R1. S1 stated that they attempted to correct the matter by finding the correct files for R1 and making copies for paramedics. However, paramedics refused to wait for S1 and left with the copies initially made before S1 acknowledged the error. During inspection conducted on 11/10/2021, LPAs Michael Hood and Angela Hood conducted a review of R1's file. LPAs observed that R1 had a Medication List with a name that was not R1's. Interview with Administrator, Andrei Dumitriu, indicated that no residents at the facility shared the name of what was indicated on the Medication List in R1's file. Administrator stated that the hospice agency providing services to R1 was responsible for placing the wrong Medication List in R1's file. During inspection conducted on 5/27/2022, LPA Michael Hood conducted a review of R1, R2, R3, R4, R5, and R6's file. LPA did not observe any other documents mixed with another resident's file, but did observe at least one required document missing from each resident's file. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents. Interview with staff member (S1), conducted on 11/10/2021, indicated that paramedics arrived at the facility to assist with transferring resident (R1) to the hospital on 11/4/2021. S1 stated that they gave paramedics R1's file. However, as S1 was making copies of documents from R1's file, they noticed that the files copied were not for R1. During inspection conducted on 11/10/2021, LPAs Michael Hood and Angela Hood conducted a review of R1's file. LPAs observed that R1 had a Medication List with a name that was not R1's. Based on interview with S1 and LPAs observations of R1's file, it is determined that paramedics received the correct facility file for R1, despite not all documents belonging to R1. Allegation: Staff may not be administering the right medications to the resident. During inspection conducted on 5/27/2022, LPA Michael Hood conducted a medication count for R2, R3, and R4, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA did not observe any errors when comparing medication count with CSMs for R2, R3, and R4. Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.