complaint·August 15, 2025

(Continued from LIC9099 Page 1) This was communicated to all involved parties, including R1's responsible party upon admission. R1 had twenty-four hour private caregivers (PC) and it was agreed upon that they would be responsible to administer medications with parameters. Staff informed that the accuracy of medications and timings were difficult due to Medical Technicians (MTs) needing to confirm what medications had been given each day. In addition, staff were informed by R1's physician that the PCs were to administer blood pressure medications. Staff informed that while the medication administration system caused confusion, no medication errors occurred with this resident based on the agreement. Staff informed that medications with parameters were locked inside R1's room and the MTs did not have access to R1's parameter medications at all times. An outside medical provider familiar with R1 (OS1) revealed that the facility would not be allowed to administer parameter medications without the help of a RN or another medical professional allowed to make medical decisions for residents. This was explained in full in a meeting between R1's family, the Executive Director of the facility, and OS1. It was determined that the PCs would have to administer parameter medications. Records Review revealed that on the Physician Communication & Progress Form, Dated 03/04/25: "[Power of attorney] POA doesn't want to discontinue parameters for Chlortalidone 25mg", "Chlortalidone to be given by caregiver." A review of the Medication Administration Record (MAR), Dated March, 2025 revealed: "Lisinopril: suspended 26 February 2025 to 31st March 2025: ON HOLD, Resident is on another BP Med with parameters private caregiver administering." A number of medications were not administered during the required prescription time, however each of those times had reasonable explanations such as: "Waiting for pharmacy to refill," "Withheld per DR/RN orders," "Given to family to give later", and "physically unable to take." The MAR did not indicate any medication errors or unexplained missing administrations. Regarding the allegation, "Licensee did not follow resident's care plan.", it was alleged that blood pressure checks were a part of the agreed upon care plan to which the facility was not consistently performing. Staff interviews revealed the process of admitting new residents and developing a care plan which did not include BP checks. The facility's New Admissions Care Plan can include but is not limited to: Oxygen order, LIC602, diet modifications, POLST, pharmacy information, etc. Staff informed that R1's care plan did not say that Blood Pressure (BP) checks were required. Staff informed that the care plan was made based on what R1's care needs were when they were first assessed by the facility and R1's Physician. Staff were to follow the care plan as directed whether the PC was there or not. (Continued on LIC9099 Page 3) (Continued from LIC9099 Page 2) Outside Source Interviews revealed no concerns for the facility's ability to follow R1's agreed upon care plan. Coronado Retirement Village Resident Assessment & Care Plan/ Functional Capabilities, Dated 2/17/25 stated that R1 had as part of their main diagnosis HTN (Hypertension). HTN was a recorded condition of R1 during the admission process. Review of the Coronado Retirement Village New Admission Care Plan, Dated 2/17/2025 revealed no mention of Blood Pressure checks required in the care plan which corroborates staff statements. Regarding the allegation, "Licensee did not provide services agreed upon in the admissions agreement.", it was alleged that meal and tray services were not received by R1. Staff interviews revealed that R1 was never charged for the agreed upon tray service in the admissions packet and this was documented and removed from the final bill. Staff informed that the responsible party wanted R1 to eat in their room; however R1 was often away from the facility with PC during the day. Due to this arrangement, the pattern was inconsistent of when staff were to conduct tray service. R1's family gave their Sixty (60)-day notice and terminated their lease. Upon receiving the notice, the facility removed all charges that were not basic rent. Staff informed that R1's family was charged basic rent for April and May sans tray service. On the 11th of March, R1 moved out and the rent was totaled and prorated as final billing. Records review revealed on the Customer Payment History from 02/04/2025 - 05/01/2025: "February, March, and May are prorated; April, rent only. Prorated to exclude tray services and meal tickets. This corroborates staff statements. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are all UNSUBSTANTIATED. An exit interview was conducted with Wellness Director Camille Nero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.