complaint·March 28, 2025

LPA reviewed Medication Administration Record (MAR) from August 2022 which revealed M1 was last given and discontinued on 8/4/2022. A discontinue order for M1 was dated 8/4/2022 from R1’s physician. LPA conducted interviews with (5) staff who cared and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 was given medication past the discontinued date. Therefore, M1 was discontinued according to the physician’s orders. It was also alleged Medication #2 (M2) was not given to R1 for (4) days in August of 2022, as the medication was not refilled in time. MAR for August 2022 revealed M2 was administered and initial by staff every day. However, the Alert Charting Notes documented on 09/04/2022 revealed R1 had ran out of M2, on 09/07/2022 staff called R1’s pharmacy to order an emergency supply of M2, and on 09/08/2022 M2 was still not received by the facility. LPA reviewed the facility’s program plan on medication refills. Page 86 revealed staff would contact the dispensing pharmacy to obtain a refill at least (7) days prior to running out of a medication. LPA conducted interviews with (5) staff who cared for and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 ever ran out of medications. Staff revealed it is the facility’s procedure to contact the resident’s pharmacy ahead of time before medications run out. Therefore, the facility did not contact R1’s pharmacy in time to refill their medication. It was further alleged that R1 was being administered medications in incorrect intervals as Medication #3 (M3) was ordered to be taken 12 hours apart and was being given (8) hours apart. LPA reviewed the MAR sheet for R1 which revealed M3 was prescribed twice daily every 12 hours. MAR for August 2022 and September 2022 revealed M3 was being given (9) hours apart with initials at 8am and at 5pm. LPA conducted interviews with (5) staff who cared for and administered medication to R1. (5) of the (5) staff interviewed revealed they could not recall any medication errors for R1, or medications given at incorrect intervals. Therefore, based on LPA’s interviews and records reviewed, the allegation that staff mismanaged the resident’s medications is substantiated based on preponderance of evidence for medications being given at incorrect intervals, and medications not being given due to medication running out for R1. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. Alter Charting Notes revealed R1 was quarantined for (10) days from 07/05/2022 to 07/15/2022. Alter Charting Notes from documented R1 was checked on for vitals, was checked on at morning and evening medication passes, and their food was delivered to them in their room. LPA conducted interviews with (7) staff who care for R1. (4) of (7) staff revealed R1 was being brought their meals into their room. Therefore, the allegation that R1 was not being assisted with their meals and inadequately fed is unsubstantiated. It was alleged “Resident sustained multiple falls due to inadequate care”. It was alleged R1 sustained multiple falls occurring July of 2022 and the facility mitigated R1’s fall risk by transferring R1 to the memory care unit August of 2022. However, it was alleged R1 did not have a medical diagnosis or change in condition to warrant moving to memory care and that R1 continued to sustain falls days after this transition. Interview with R1 was unable to be conducted as R1 has since passed away. LPA conducted interviews with (7) staff who provided care for R1. (6) of (7) staff revealed R1 sustained falls while at the facility and R1 was a fall risk. (7) of (7) staff revealed the facility mitigated R1’s falls by providing R1 with a “Tempo” watch they could use as a pendant to summon staff, and to detect movement if R1 had a fall. R1 was on checks at least every (2) hours, during medication passes, and at mealtimes. R1 was also provided with escorts when ambulating. Regarding the allegation that the facility placed R1 in memory care to mitigate R1’s fall risk, (4) of (7) staff revealed R1’s confusion and decline in condition contributed to their fall risk and R1 being placed in memory care. (4) of (7) staff revealed R1 had a qualifying memory condition and denied they were solely placed due to their falls. Review of R1’s Physician’s report dated 06/09/2022 revealed R1 had a memory condition. The facility’s program plan was reviewed for fall risk mitigation which revealed on Page 111; when a resident experiences a fall staff will follow up with service plan updates. Records review of “Internal Incident Reports” for R1 revealed they sustained (3) unwitnessed falls in July of 2022 when R1 was isolating in their room due to a medical condition. The Alert Charting Notes for R1 revealed checks conducted by staff, and documented R1 experiencing increased confusion starting 7/7/2022. The Service plan for R1 was updated 7/7/2022 citing reason for assessment as “change in condition”. The admission agreement revealed R1 was admitted to the memory care unit on 08/28/2022. Alert Charting notes for R1 revealed (2) unwitnessed falls after R1 was admitted to memory care, with a fall documented on 09/06/2022. An Appraisal of Needs was conducted for R1 on 09/07/2022 which revealed R1 had decreased mobility and was frequently disoriented requiring repeated verbal prompts and directions. R1 required a (1) person escort and extensive assistance with transfers. Therefore, the interviews and records review show the facility conducted checks, and reassessed R1 after falls to meet R1’s care needs as outlined in their program plan. It was also alleged the facility gave a 24 hour ultimatum for R1 to get 24/7 care due to their falls. LPA conducted interviews with (2) administrative staff. (2) of (2) staff revealed after (3) falls, the facility suggested a 1:1 service for R1 for the first 24 hours to monitor for any subsequent falls. Staff revealed options were provided for the 1:1 for care staff, family members, or an outside agency to provide the service. Staff denied they obligated R1 to obtain any service and suggested the services due to R1’s fall risk and care needs. Therefore, the allegation that R1 sustained multiple falls due to staff neglect is unsubstantiated. It was alleged “Facility staff did not keep the facility clean and sanitary ”. It was alleged that R1’s room was observed with dried feces on the floor next to R1’s bed, on R1’s bathroom wall, shower, and shower curtain. It was alleged staff had called housekeeping to clean the room but the next day R1’s room was observed in the same state. Interview with R1 was unable to be conducted as R1 has since passed away. LPA received photos of brown stains on the floor of a shower, on the base of a shower curtain and tile in the shower. The photos did not provide dates, times, and could not be matched to R1’s room. LPA conducted interviews with (7) staff who cared for R1 who revealed they could not recall a time where R1’s room was left with dried feces and not cleaned for more than (1) day. Therefore, the allegation that the staff did not keep R1’s room clean and sanitary is unsubstantiated at this time. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted, and a copy of this report was provided.