complaint·January 7, 2025

LPA did a 10-day visit to the facility on 11/21/24 to gather records, interview staff, and observe residents. LPA conducted interviews with the Reporting Party (RP) on 11/20/24, a Family Member (F1) on 11/20/24, a credible witness (W1) on 1/2/25 and licensee on 11/20/24. F1 stated they visited the facility on 11/18/24 at approximately 4:40 p.m. F1 entered the facility and noted R1 was in the living room with other residents, immediately F1 noticed R1 appeared very agitated, this was noted because R1’s “eyes were wide” and was observed “slamming (their) wrist on arm rest, because that was the only part that was loose”. F1 saw that R1 had 4 “white plastic trash bags” which were wrapped, 2 on each arm, from the elbow to the wrist. F1 looked to Staff 1 (S1) and asked, “what is going on”, “why are (R1’s) arms tied down”? S1 stated “(R1) been very upset” “R1 very agitated”, S1 added they had just “gave (R1) Ativan.” F1 inquired into the reasoning for the restrains and S1’s replied, “I gave Ativan it’s going to work.” F1 told LPA that S1 immediately removed “white trash bags” and set them on a chair beside R1. F1 was unable to take photo before staff removed restraints from R1. F1 described the white trash bags as standard white bags with red ties. A box of these type of trash bags were observed during LPA’s visit on 11/21/24. LPA obtained and reviewed text communication between F1 and Licensee, who advised the Licensee will follow up with staff on proper procedures moving forward. Licensee does not deny the accusation of the restraints in the text and told F1 “I talked with (S1) today and (they) said it was the first time (S1) saw (R1) so agitated. I told (S1 they) cannot restraint (them) like that and instead will use medication like lorazepam to calm (them) down.” F1 moved R1 from the facility effective 11/23/24. During LPA interviews with Licensee, Licensee claimed that plastic white grocery bag, with red writing on it, were used to “keep the wheels of the wheelchair from moving”. Licensee got one of the grocery bags to show what the facility claims was used. This explanation is inconsistent, as the wheelchair has a built-in locking mechanism. W1 advised they directed staff to follow medication prescription, which allowed facility to give Lorazepam (aka Ativan) and Quetiapine (aka Seroquel). Continued on 9099-C After incident, during facility visit on 11/21/24, W1 provided caregivers additional education for R1’s agitation such as giving prescribed medication, chamomile tea, calming music, and advised that at no time were restraints acceptable. W1 further stated during the visit on 11/21/24 they spoke with a caregiver. W1 stated a caregiver advised that bags were used to prevent wheelchair from moving. W1 stated to LPA that they found the caregivers “explanation did not make sense” because the wheelchair locks work. Additionally, W1 provided LPA with a picture of bruises to R1’s hands, W1 stated R1 bruises easily, but usually it is on the forearm, this image was taken because the bruising was in between the fingers which W1 stated is not a common area for bruising on clients. During subsequent visit LPA reviewed Hospice notes, care plan, and medication list. LPA noted the plan of care and notices remind staff to contact Hospice agency if any questions, changes, or concerns. During evening event in question, licensee admits that resident was agitated, but no request was made to Hospice prior to family reaching out in the following days. Based on LPAs observations and interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Health and Safety Code 1569.269 (a)(1)(10) are being cited on the attached LIC 9099D. Exit report given, copy of citation, and appeal rights printed. during LPA interview with F1, F1 stated that during the incident of agitation described in the allegation, F1 asked if R1 received Parkinson’s medication today, S1 stated “(R1) had all (their) medication.” This was at time of visit on 11/18/24 being around 4:40 p.m. F1 also stated they sat with R1 until they were calm and falling asleep. Caregivers put R1 to bed, which was before 6:00 p.m. During incident on 11/18/24, it was alleged that resident had received all medication by 4:40 p.m. and was put to bed around 6:00 p.m. The concern is medication is not given as directed and is given inconsistently between shifts. During interviews and records review regarding Parkinson’s medication Carbidopa-Levodopa the following was noted, on 01/7/25 during interview with Back-up Administrator the Medication Administration records (MAR) were reviewed and noted to have required administration times, back-up administrator stated the direction is for staff to wake up R1 in the evening around 8:00 p.m. to ensure the bedtime medication is given at the proper time. Back-up Administrator believes that S1 miss spoke when stating all medications had been given by 4:40 p.m. due to the incident that occurred when F1 arrived which worried S1. LPA reviewed and observed that the MAR was noted and initialed during the evening of the incident and that scheduled medication per the MAR was given as ordered. During interviews and record review regarding PRN medication the following was noted: On 11/20/24 during visit LPA obtained a copy of medication sign out sheets for Lorazepam and Quetiapine. Sign out sheet for Lorazepam and Quetiapine do not record more than one dose of each PRN’s given on 11/18/24. During medication review LPA did medication count for PRN medication and noted that Lorazepam was expired, and the count was off by 2 doses. Quetiapine count was off by 3 doses. On 1/7/25 LPA reviewed all available records from facility, LPA was able to find PRN orders stating orders for Lorazepam “give…every 4 hours as needed for…anxiety…” If the allegations of staff providing 3 doses is correct, this would be within the orders allowed. Based on LPAs medication review, interviews conducted and record review(s), although the allegations may have happened there is not a preponderance of evidence, therefore the above allegation(s) is found to be UNSUBSTANTIATED at this time. Exit interview conducted and copy of report given.