Complaint·February 20, 2025

Based on interview and record review, it was revealed that R1’s change of condition due to overdose was reported to R1’s responsible party, but not reported to Licensing department per regulatory requirements. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided. Allegation: Staff did not prevent resident from an overdose while in care. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was determined that on 11-14-24, R1 informed facility administrator she was going to a local store and left facility. At approximately 9:30pm on 11-14-24, R1 returned home and called 911 stating she took 42 aspirin pills while walking back from the store. R1 was transported to a local hospital for services and released early morning of 11-15-25 with transport back to facility. A review of physician’s report for R1 determined R1 is able to leave facility unassisted. Additional interviews conducted revealed facility staff was aware of R1’s general whereabouts. As a result, based on R1’s ability to leave facility unassisted and staffs’ knowledge of R1’s whereabouts after being informed, there is not a preponderance of evidence to conclude staff did not prevent resident from an overdoes while in care. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff cancelled resident’s mental health appointments. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was revealed that R1 has scheduled psychiatric appointments. Additionally, interviews and record reviews revealed staff have made previous attempts to schedule additional appointments for R1. LPA did not observe or receive documented or verbal evidence of any cancelled appointments during this investigation. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.