Complaint·June 6, 2023

An audit of R1’s daily medication, prescribed to manage R1’s primary medical diagnosis, confirmed R1 missed approximately 4 doses. Additionally, on 3/20/2023, R1’s PCP placed a “hold” on R1’s blood pressure medication yet facility staff continued to administer this medication for approximately 8 days after the medication hold was issued. Interviews with outside sources revealed that the correct administration of medication was required to treat R1’s acute health condition. Records review determined that when medications were administered correctly, R1’s baseline remained stable, and they were primarily able to manage their own activities of daily living (ADLs). Interviews and records reviews revealed on May 12, 2023, R1 was found unresponsive by facility staff and sent to the Emergency Room (ER). Outside source records revealed at the time of the ER admission, R1's blood pressure level was out of range, and R1 still tested positive for a UTI. Outside source interviews and record reviews revealed several of R1’s medications that were not given as prescribed had side effects including, but not limited to: confusion, lethargy, and loss of bladder control. Similarly, the presence of a UTI also had symptoms such as confusion, incontinence, and frequent falls. An outside source interview and facility records review revealed facility staff reassessed R1 from a care level 2 to an increased care level of 5. The reassessment occurred during the time staff were not administering medication as prescribed, which contributed to acute side-effects that led to R1 requiring additional care. A facility record review revealed the reassessment included additional “escort services” due to R1 having falls. However, interviews with staff and an outside source and LPA observation after R1’s Responsible Party (RP) was notified about the change in level of care revealed R1 was seen ambulating throughout the facility on several occasions, unaccompanied by an escort. In addition to R1’s incidents of medication errors noted above, multiple staff interviews revealed they had observed many other medication errors during this time. A facility records review and review of outside source evidence confirmed medications were found unsecured throughout the facility. Records review also revealed on several occasions, facility staff notated and communicated the medication errors to facility management. Interviews and records review also revealed incidents where pills were found on the floor throughout the facility, including pills found in R1’s room that were not prescribed to R1. The facility census was 80 residents during this time, and records showed that approximately half of residents were assessed at a care level of 0, while slightly over one-fifth were at level 1, and the remainder of residents ranged between levels 2-5. However, a review of records of residents who were assessed at a care level of 0, revealed that these residents were in fact provided care services by facility staff. Based upon individual records review, the assigned care levels gave an inaccurate account of the overall amount of care required to meet residents’ actual needs. A review of the facility staff schedule (that included caregivers and med-techs) revealed there were shifts that only had one staff member scheduled on duty. Interviews further revealed staff stated they felt overwhelmed and unable to meet residents needs due to working shifts without assistance and staff consistently indicated this was because of the facility being understaffed. It was alleged staff neglect resulted in health conditions. Additionally, it was alleged staff did not administer medication as prescribed. An interview conducted with an outside source and facility records review revealed Resident1 (R1) was diagnosed with a Urinary Tract Infection (UTI) on November 23, 2022. Outside source and facility staff interviews, as well as a review of facility and outside source records revealed staff did not administer R1’s antibiotic which was prescribed to be given on the same night of R1’s UTI diagnosis. A facility records review and interviews conducted with outside sources also revealed facility Staff 2 (S2) routinely gave R1 their antibiotics with a large amount of water. Due to their primary medical diagnosis, R1 would regurgitate from the water intake and expel the prescribed antibiotic. Staff and outside source interviews revealed on one occasion R1’s antibiotic was found in the trash, and S2 was observed re-administering the same medication to R1 after retrieving it from the trash. On another occasion, one of the antibiotic pills was found in R1’s sink. A follow up medical appointment on January 23, 2023, determined R1 was still positive for a UTI, and the infection had spread. Outside source interviews revealed that during R1’s follow up medical appointment, R1’s Primary Care Provider (PCP) recommended the medication be given in an alternative manner. Interviews conducted with an outside source revealed that instructions were provided to facility staff. Staff and outside source interviews revealed when R1 was given their medication as recommended, they were able to take the medication with ease; however, S2 continued to give large amounts of water causing R1 to continue to regurgitate the water and the medication. Interviews and record reviews revealed R1 began to refuse the antibiotic when it was administered by S2. It was alleged facility staff did not provide healthful accommodations . An outside source interview revealed R1 had an occurrence of a bowel accident and R1’s linens had remnants of fecal matter that staff did not address by providing clean linens. A review of secured documentation corroborated the allegation. Interviews with facility staff also confirmed finding residents left in soiled undergarments and linens on multiple occasions. Further review of documentation noted R1's trash to be overflowing with used incontinence care supplies. Additionally, staff interviews revealed they had observed resident rooms to be unkempt, and residents left in soiled undergarments due to the facility’s lack of staff. It was also alleged staff were not following reporting requirements. Interviews conducted with facility staff and outside sources corroborated being verbally intimidated or reprimanded by facility management when reporting incidents. Staff interviews revealed being trained on a reporting system to input incidents that occurred during their shifts; however, when they reported incidents as they had been trained, they were reprimanded by management. Staff interviews also corroborated that facility management had the capability of deleting or manipulating submitted reports. An interview conducted with a staff member revealed taking pictures of their reports prior to submission as proof that they fulfilled reporting requirements. A review of secured documentation confirmed staff were instructed not to report incidents, mostly noted as medication errors. Staff interviews revealed being shouted at by management, and observing other staff being reprimanded after they reported an incident. Interviews with facility staff also revealed that during a meeting, management instructed staff to refer Licensing to management if being questioned about anything related to a resident’s health condition. Additionally, it was alleged staff intimidated residents . Interviews conducted with several staff members confirmed having directly witnessed facility management shout at and/or be rude to residents in care on multiple occasions. An interview with Resident 2 (R2) revealed that after submitting a complaint anonymously, facility management confronted them in an intimidating and harsh manner and claimed they had knowledge of R2’s complaint. It was also alleged staff were not provided with appropriate training . Interviews conducted with residents and staff corroborated staff were not provided with required basic training to meet resident care needs. An interview with Staff 4 (S4) stated they started training but by their third day at work they were left providing care on their own, with no other staff present to assist. Interviews with facility staff, staff records review, and a review of other secured documentation confirmed untrained care staff were working in roles they had not been hired or trained for. Additionally, it was alleged staff intimidated residents . Interviews conducted with several staff members confirmed having directly witnessed facility management shout at and/or be rude to residents in care on multiple occasions. An interview with Resident 2 (R2) revealed that after submitting a complaint anonymously, facility management confronted them in an intimidating and harsh manner and claimed they had knowledge of R2’s complaint. Based on records reviews, interviews and observations, the above allegations were determined to be substantiated. A substantiated finding means the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on the LIC 9099-D. An exit interview was conducted with CBD Maezze and MD Zamudio and a copy of this report and Licensee/Appeal Rights [LIC 9058 (3/22)] were provided to CBD Maezze and MD Zamudio . Signature on this form acknowledges receipt of the documents. .