complaint·May 26, 2022

During the investigation, LPA interviewed (2) Administrators and (3) caregivers and a family member and reviewed documentation pertaining to medication administration for (3) current residents. Resident (R1) moved to the facility on 1/22/22 around the afternoon time and moved out on 1/24/22 early in the morning. Allegation: Resident not administered medication as prescribed. Allegation is resident (R1) is required to take melatonin once a day at 10:00pm but instead was being administered two melatonin at noon. Interview with (2) Administrators indicated that resident (R1) refused medications starting on Sunday, 1/24/22 and would only accept from family members. One staff stated "(R1) re fused medications- she spit them out- we put them in applesauce and she still spit them out". A second staff stated he was not aware of any medication issues, and a third staff stated "I never gave her medications- I was off work".Administrator confirmed there is no documentation on file as resident's family requested that any documentation be shredded after resident moved out and the placement agency took some documents also. LPA and staff (S1) reviewed medications for (3) residents (R2-R4) on 5/26/2022, including physician's orders, Centrally Stored Medication Record (LIC622) and Medication Administration Record (MAR) for May 2022. It was determined that resident (R2) had not received Docusate on 5/26/22, due to waiting for a refill, but had received it from 5/1/22- 5/25/22. For resident (R3), Klor-Con-8-MEQ and Docusate 200mg were last administered on 5/25/22 in the morning, due to waiting on a refilled supply. Additionally, LPA observed an empty bottle of Atorvastatin-Calcium 40 mg, filled on 8/16/2021, and an opened bottle of Melatonin 10mg, to be stored with R3's current medications; Neither medication was listed on the May 2022 MAR and prescription orders, dated 8/25/2021 show that each medication is scheduled to be taken once daily. For resident (R4), LPA and S1 counted 23 tablets of PRN Alprazolam 0.5 mg, filled on 5/15/22, and determined that 7 tablets were administered since 5/15/22; however, there is no documentation on file as required. New orders were written on 5/24/22 to discontinue Alprazolam and start PRN Haloperidol 2 mg. Administrator confirmed that the medication Alprazolam, was given but not documented. cont on 9099C(2).. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility did not assess resident prior to admission. Allegation is resident (R1) wa s not physically assessed prior to residing at the facility and placement agency and Licensee agreed to accept resident to move in. Administrator stated on 2/2/22 that she did not evaluate resident in person, prior to admission, and asked skilled nursing for paperwork, including resident's physician's report. Administrator further stated that she talked to resident's daughter before admitting her. Administrator confirmed there was also no paperwork kept on file after resident moved out. LPA was not able to contact placement agency representative to confirm the pre-appraisal process used. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (2) deficiencies are issued on the 9099D pages. Exit interview. Copy of report and appeal rights provided to Administrator. 9099C(1).. Resident's family member said one Administrator stated there were (2) melatonin in a picture family member texted to Administrators but could not explain why there were (2) "pre-poured" for resident. Family member also stated that when she visited on Sunday, 1/23/22, in the morning, R1 was asleep in the chair in the living room and staff stated "I guess she took her medications". Another staff stated that resident woke him up at 4 am and wouldn't sleep. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning 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. Allegation: Staff administered incorrect medications. Allegation is when R1's family member requested to see R1's medication. RP stated staff (S2) brought out a white basket full of medications with R3's name on it and none of the medications belonged to R1. It is unclear how long R1 was being administered R3's medications. LPA interviewed staff (S2) and asked if there was a medication mix-up with R1's medications and another resident's medications. S2 stated "No, there was not a mix-up with the medications"- the "Medications are already in a pocket", ready to administer. S2 showed LPA the small walk-in closet with shelves where resident medications and binders are kept. LPA observed multiple residents' medications, each in a labeled basket. LPA asked how S2 may have grabbed the wrong basket if each basket has a name on it. S2 then spoke quickly, stating that during the video call R1's family member pointed to the white basket and said "that basket" when asked which basket has R1's medications. S2 further stated that R1 took medications once only, from 1/22/22 through 1/24/22, when her family member gave them to her. Resident moved out on 1/24/22. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning 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. Copy of report provided to Administrator.