complaint·September 8, 2023

9099A-C1... The Administrator stated (R1’s) POA called (R1) a second time, on 5/11/23, during dinner, while (R1) was eating/chewing and so he answered the phone for (R1) and told (R1) the POA that (R1) was eating chicken. The Administrator confirmed that (R1) was served pizza for lunch and chicken with salad for dinner on 5/11/23. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Staff did not provide nutritious meals to resident in care . Complaint alleges that (R1) was admitted to hospital because the facility was not giving (R1) his medication and he was feeding him improperly. Primary staff (S1) confirmed that (R1) did have a "special diet" that included "less bread" and less potato and rice, stating "once a week we would give him frozen pizza"- usually on Thursdays when the Administrator is here. (S1) confirmed the facility serves a "routine menu" which includes serving oatmeal twice weekly on Wednesdays and Saturdays and cold cereal on Tuesdays and Fridays. The Administrator also confirmed that (R1) had a "special diet" and staff would serve meals with "low carbs and usually less bread and carbs" due to (R1’s) diagnosis of Diabetes. The Physician’s Report, dated 3/3/23, indicates that (R1) needs a special diet consisting of low carbs. The Administrator confirmed that he served (R1) pizza on Thursday, 5/11/23, which was the scheduled lunch meal that day. The Administrator stated that he picked up medication refills, in person, at the pharmacy on 5/9/23 and medication was administered as scheduled following picking up the medications. LPA observed fresh produce on hand on 9/8/23. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. cont on 9099A-C2... 9099C-2-.. Allegation: Administrator did not obtain refill medication for resident in care. Complaint alleges that the Administrator did not tell the POA that (R1) needed his medication refilled and the Administrator did not refill his medication. The Administrator stated that (R1) missed scheduled medications starting on 4/28/23, due to not receiving the refills in the mail, stating he called the VA on Mon, 5/8/23, and picked up the meds on Tues, 5/9/23. The Administrator asserted that (R1) "always had an insulin pen" but "ran out of pills for approximately two weeks". A representative with the VA stated to LPA that they do not offer the option of “automatic refills” and a medication refill must be requested online, if there are refills available, or by phone, if there are no remaining refills. The representative explained the veteran or the caregiver can go online to their website to request the refill. Administrator stated called on/around 4/21/23 and requested refills of multiple medications, 7 days before the medications would run out. On 5/8/23, the pharmacy left a message that the medications mailed had returned due to a wrong address. LPA was not able to confirm any specific information with the VA pharmacy without a signed consent due to HIPPA. (R1) does not live at the facility any more and the complainant was anonymous. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Allegation: Administrator did not seek medical attention for resident in care. Administrator did not see that (R1’s) condition was changing, his sugar was high, and he had not had his medication. A primary caregiver (S1) stated Wednesday, 5/10/23, he observed (R1) to be "shaky" and "declining a bit". (S1) indicated he was not working on Thursday, 5/11/23, as it was his regular day off, but he returned and was back on shift on 5/11/23 around 8:30-9:00 pm. (S1) stated that (R1) was watching television and went to the bathroom by himself and (S1) told him to "lay down", stating 10-15 minutes later, (R1) was "still on the toilet and he was very confused". cont on 9099C-3.. 9099C-3.. (S1) indicated that resident (R1) was sent to the Emergency Room on 5/12/23, when he was working. (S1) explained that he observed (R1) Friday morning, around 7:30 and (R1)'s condition was "more serious" and was "shaking every minute and more confused" so he called the Administrator. (S1) explained that (R1) was not able to give himself the normal insulin injection. (S1) explained that the Administrator called 9-1-1 around 8:15 am as (R1’s) condition "definitely got worse" and this was right before the daughter called. (S1) commented that on Wednesday, 5/10/23, (R1) "seemed at baseline" and then on "Friday morning, I really noticed" a change. The Administrator stated that (R1) was seen by a home health nurse on Thursday morning, 5/11/23 and (R1) was appearing to be a "little confused" at that time, but the nurse who checked him said it wasn’t necessary to call 9-1-1 but to monitor (R1). The Administrator stated (R1) was "not like usual but it was not alarming". Documentation shows that (R1’s) blood sugar was taken in the morning on 5/11/23 and was “200”. It was not taken again until the morning of 5/12/23, when it read “225”. (R1’s) blood sugar measured “147” on 5/9/23 and “157” on 5/10/23. Administrator stated (R1's) blood sugar was around 140-160 usually in the morning but it was high around 200-225 on 5/10/23 and 5/11/23 after receiving the refilled medications. (R1) was admitted to the hospital on 5/12/23. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Copy of report provided. 9099C-1.. Allegation: Staff did not dispense medication to resident for several days. Complaint states that when the POA told the Administrator that (R1) would not be returning to the facility, the Administrator indicated (R1) did not have his medication for a couple of days. The Administrator stated that usually (R1’s) medications are sent by regular USPS and are received within 5-7 days and confirmed that the VA would send a 30-day supply of each medication and they usually reach out when they are mailed. The Administrator stated that he phoned in a refill for multiple medications on/around 4/21/23 when there was approximately (7) days supply remaining on the medications. Administrator stated that when the medications had not arrived by/around 4/28/23, he called the VA pharmacy again and (R1’s) POA to advise the medications were late and was informed by the pharmacy the medications were sent to a prior address for (R1). (R1’s) POA indicated she would look into the address VA had on file and request it be updated. On 5/19/23, LPA listenedd to a voice message received on the facility land line on 5/8/23 from the "outpatient pharmacy" at the VA Mather location. LPA heard the caller state that "the prescription was mailed but returned back to us" and advised the Administrator to contact them at the number provided. The Administrator stated that on the morning of 5/9/23, he went to pick up the medications in person at the VA pharmacy, and (R1) was then administered medications as scheduled. The Administrator confirmed that (R1) did not have scheduled medications from on/around 4/28/23- 5/9/23; however, he always had a supply of insulin. The facility does not maintain a Medication Administration Record (MAR) currently. The Administrator stated that (R1’s) son picked up his belongings, including unused medications on 5/17/23 and an ending medication inventory count was not taken but the bottles were almost full since they had been picked up on 5/9/23. There is a separate citation issued for this deficiency. The Administrator stated that (R1’s) physician was not contacted to advise (R1) did not receive medication during the (2) week period because it is difficult to get in contact with VA physicians, but the pharmacy was aware and the POA was also. LPA finds the allegation to be SUBSTANTIATED- meaning that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies (2) are cited per Title 22 and the Health and Safety Code. Appeal Rights provided, exit interview conducted.