complaint·September 3, 2024

Staff (S1) stated that dementia residents are not accepted at the facility. S1 stated that R1 makes their own decisions and confirmed that R1 does not use a cane. S1 stated that there is no obligation to contact the POA for any reason. S1 stated that once residents no longer have mental faculties to make decisions, they may no longer reside at facility. S1 further stated that no prescriptions were delivered from Pill Save to R1. Administrator stated that at no time was R1’s prescription order transferred to Pill Save. Administrator provided prescription order packing slips from Model Drug orders during the period of September 25, 2023, through November 24, 2023. R1’s prescriptions continued to be delivered from Model Drug. There is no evidence to support that R1 prescriptions were filled by Pill Save. Administrator stated that they spoke to residents about using the facility’s preferred pharmacy, Pill Save, as it is it is a local pharmacy that provides 24 hour delivery and more responsive customer service. Administrator stated that a care conference was arranged with residents to express their complaints or concerns. Administrator spoke with residents as well as primary care providers. Administrator stated approximately 40% of residents rolled their prescription order to Pill Save. Administrator stated that residents that wanted to change their pharmacy did so in writing. It was verbally verified that roll-over could take up to a week. Administrator further stated that he provides residents with a menu of 5 local Home Health Services options, but there is no obligation to choose from the 5 presented. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. On the allegation: Staff mishandled a resident's medications while in care. It was alleged that staff did not follow doctor’s order on prescriptions as R1 was overly medicated and that lorazepam should have been discontinued. It was alleged that the Medication Administration Record (MAR) Reports reflect a sedative was prescribed as a PRN and was not properly recorded by Med Techs. LPA Miller conducted a review of documents including a physician’s letter dated 10/30/2023, requesting that R1 discontinue lorazepam. This request was notated in R1’s file. LPA reviewed all medications in cart for Resident 1 and compared it to the MAR. There is no record of lorazepam being administered to R1 during the period of November 2023 through February 2024 or being over medicated. LPA observed a printout in R1’s file from a hospital visit on 12/20/23 from Sierra Regional Medical Center. (Continued on 9099-C) The printout lists current medications that included the lorazepam, as the hospital had a list of old medication orders on file. There was no evidence to indicate the facility provided lorazepam to R1 after the medication was discontinued. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. On the allegation: Facility Staff failed to provide requested records to designated representative. It was alleged that Staff did not provide all records as requested by responsible party. Responsible party confirmed they received documents from the facility, but did not feel it was complete based on the number of documents provided. Administrator stated that all requested records were provided to the responsible party. Administrator was unclear what additional documents were being requested. Administrator stated the responsible party acknowledged receipt of the records in December 2023 and no further requests were made. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. On the allegation: Facility staff failed to provide current medical information to emergency responders. It was alleged that Staff sent R1 to the hospital with an outdated Physician Order for Life-Sustaining Treatment (POLST). During the initial visit, Staff 1 reviewed the emergency services binder at the front desk and R1 did not have a POLST in the file. Staff 1 then reviewed R1’s file and found that R1 had two different POLSTs, but the directives indicated were identical. Administrator stated they remove outdated POLSTs from resident files, to ensure only the most current is in the file. LPA reviewed a copy of R1’s POLST dated 12/18/2023 and only observed one POLST on file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An Exit interview conducted and a copy of this report issued.