complaint·March 18, 2025

[CONTINUED FROM LIC 9099] During the complaint allegation time frame, R1 was being followed by an outside healthcare management agency. R1’s primary care physician (PCP), dietician, and other medical professionals were based at this agency. The Complainant claimed that on 01/16/2025, PCP changed R1’s order/prescription for Glucerna nutritional supplement from one (1) bottle per day to two (2) bottles per day. They said that from 01/16/2025 through 02/12/2025, there were days Licensee gave R1 one (1) bottle instead of the prescribed two (2). Interviews of facility manager and multiple caregivers unanimously showed: As of the commencement of CCLD’s investigation on 02/20/2025, all staff were under the impression that R1 was supposed to receive just one (1) bottle of Glucerna per day in the evening, to be given only if their blood sugar was less than 300 mg/dL. All staff interviewed said they were following this order. All staff interviewed also denied the existence of an order for R1 to take two (2) bottles of Glucerna per day. LPA reviewed dated and time-stamped electronic orders from R1’s healthcare management agency, which showed: Prior to the complaint allegation time frame, R1 was indeed prescribed just (1) bottle of Glucerna per day, to be given only if their blood sugar was less than 300 mg/dL. While R1 did undergo a nutritional reassessment by their dietician on 01/15/2025, the evidence did not show that there was yet an active doctor’s order changing their Glucerna regimen during the complaint allegation time frame, let alone that such an change order (if it even existed then) was successfully transmitted/communicated to Licensee during the complaint allegation time frame. Rather, the healthcare management agency's first electronic recording of the doctor's order to increase R1’s Glucerna to two (2) bottles per day appeared several days after CCLD commenced its complaint investigation. Facility staff followed this later order, as soon as it was received. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not give R1 their nutritional supplement as prescribed. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Co-Administrator Nikita “Nikky” Mundhada, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.