Complaint·July 1, 2025

[CONTINUED FROM LIC 9099] Records and interviews of R1 and facility staff aligned to show: Leading up to the complaint time frame, R1 was diagnosed with depression and a chronic neurological condition which caused them constant and intense pain. R1, who was their own responsible person, was also responsible for storing and taking their own medications, which included opioids. On 05/25/2025, R1 told Staff #1 (S1) that they were in so much pain they wanted to kill themselves by ingesting an entire bottle of medication. S1 quickly escalated this information to facility manager Staff #2 (S2). S1 and S2 both told LPA they interpreted R1’s statement at that time as a credible plan to harm self, with access to method/means present. R1 told both S2 and LPA they were speaking dramatically and not literally on 05/25/2025, and had no desire to commit suicide. Records and staff interviews further showed: Licensee took quick action that day to safeguard R1, which included calling 911 and notifying R1’s assigned physician (P1). R1 declined to go to the hospital for a psychiatric evaluation. P1 told first responders via phone they supported R1’s decision. R1 thus did not go to the hospital. Licensee also utilized a third-party home-care agency to provide continuous one-on-one supervision of R1, pending a psychiatric assessment to clear R1 of suicide-risk. That same day, Licensee also requested from P1 an updated list of prescribed medications for R1, which Licensee needed to successfully reevaluate R1’s ability to accurately self-manage their medications per their prescriptions. However, P1 replied they were out of town, away from their computer, and could not timely send such a list. In lieu of a fast response from P1, and with R1’s consent, Licensee arranged for R1 to be evaluated face-to-face on 05/28/2025 by a mobile, third-party psychiatric nurse practitioner (P2), operating under the oversight of a physician assistant (P3). P2 and P3 were not entirely new providers; each healthcare professional had previously treated/visited R1 in the past. P2’s psychiatric assessment concluded that R1 had “low to moderate risk” of suicide. However, P3 subsequently authored an updated LIC602 Physician’s Report, indicating that facility staff should store and administer R1’s medications. On 06/02/2025, facility managers met with R1 to take over storage and management of R1’s medications. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 812-C, 1 of 3] On 06/03/2025, P1 evaluated R1 via a tele-medicine appointment, then sent a signed letter to Licensee essentially saying that while P1 was aware of what earlier transpired on 05/25/2025, they had been assigned to R1 over two years and believed R1 was “not actively suicidal.” P1 determined that one-on-one supervision was not needed, that evaluation by a psychiatrist was not needed, and that R1 should go back to independently storing and taking their own prescribed medications. Upon receipt of this letter, Licensee discontinued one-on-one supervision for R1. However, Licensee then requested from P1 an updated list of R1’s prescribed medications and an updated LIC602 Physician’s Report showing that R1 could self-manage medications (to override/overturn the earlier LIC602 completed by P3). As of 07/01/2025, Licensee had not received these documents from P1 and was thus continuing to centrally-store and manage R1’s medications. CCLD interviewed R1 twice for this case, a few days apart, finding: To the lay observer, R1 was alert, oriented, and articulate, with no signs of memory-impairment. R1 continued to deny intent to commit suicide. However, LPA identified areas of potential concern, requiring further research, assessment, and/or education w/ R1: 1) The pharmacy prescription label on R1’s bottle of Oxycodone immediate-release tablets for pain lacked clear dosage instructions, saying instead, “Please see attached for detailed instructions.” The corresponding pharmacy paperwork that arrived with this medication also said, “Please see attached for detailed directions.” When LPA asked R1 how they typically took their Oxycodone medication, R1 gave inconsistent answers regarding the time-spacing and maximum number of tablets they would consume per typical day; 2) During his 06/27/2025 site visit, LPA observed inside R1’s room an empty bottle which once contained Oxycodone extended-release tablets for pain. The prescription label showed one tablet was to be taken twelve (12) hours apart. R1 said they took this medication just twice per day. However, per the label, sixty (60) tablets were dispensed on 06/02/2025; that R1 ran out of tablets suggests there were days earlier in the cycle when R1 consumed more than two tablets per day; 3) Regarding their as-needed Clonazepam tablets for anxiety, R1’s statements showed they did not consistently adhere to the prescribed time-spacing instructions for this medication; 4) Regarding their as-needed Hydroxyzine tablets for itching, R1’s statements showed they did not adhere to the prescribed maximum daily dose for this medication; 5) LPA observed multiple bottles of wine/liqueur near R1’s bed. Staff interviews showed a recent increase in R1’s ordering of wine/alcohol from outside sources (which have been dropped off at the facility’s front desk). Per R1’s own statements, they are nearly continuously medicated with opioids during their waking hours. P1 should clarify for Licensee if alcohol is contraindicated with R1’s current medications. [CONTINUED ON LIC 812-C, 3 of 3] [CONTINUED FROM LIC 812-C, 2 of 3] The totality of available evidence showed: R1’s verbalizations on 05/25/2025 raised a credible safety concern at that time, to which Licensee diligently responded. Licensee’s taking over control of R1’s medications starting 06/02/2025, following the receipt of P3’s written medical assessment on R1 recommending such, was also justified. As the primary care physician of R1 for over two years, P1’s authority in this case supersedes that of P3’s. P1’s signed 06/03/2025 letter to Licensee was indeed valid physician instruction. However, California Code of Regulations (CCR) Section 87463(e) supports the right and responsibility of Licensees to conduct their own care assessments parallel to medical assessment(s). When health/safety concerns and/or unresolved questions are identified, regulation requires Licensees to further communicate with the physician to obtain recommendations on these issues. However, Licensees retain some independence in forming the written record of care that the resident shall receive while living at the facility, particularly when provisions reasonably uphold resident health/safety in balance with resident rights. At the conclusion of CCLD’s complaint investigation, there remained unresolved questions and documentation which P1 needed to clarify/address for Licensee. Such information is needed to effectively evaluate if R1 can safely and accurately manage their own medications, or if R1 can be educated/coached to do such, if applicable. Based on records and interviews, a preponderance of evidence does not exist at this time to show that Licensee did not allow R1 to keep their own medication without just cause. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Executive Director Julia Lopez and Resident Services Director Ashley Baino-Jaimes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.