complaint·October 2, 2025

RP states that carbidopa levodopa was often not on time as directed by doctor. Interviews with two witnesses state R1 had expressed concern that the Parkinson’s medication carbidopa levodopa was not given as ordered. Interview with witnesses, F1, and administrators all state medication orders for Parkinson’s would change “all the time.” LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Records (MAR), these records along with Physician Visits notes showed orders for Carbidopa changed at least 4 times since November of 2024. A CSMDR medication note is written in that an order for 2 tabs by mouth 6 times a day started on 10/21/24 by Physician #1. 11/2/24 2 tablets 3 times a day by Physician #1. 12/3/24 2 tabs by mouth 6 times a day by Physician #1. Physician Visit notes by Physician #2 on 3/21/25 stated to “remove the extra 2 carbidopa…” then lists 5 different times to distribute. Then another change by Physician #2 of this medication on 4/21/25 back to 6 times a day. LPA reviewed the CSMDR and found that the 2 orders noted on the Physician Visit notes were not updated on the CSMDR records and the MAR due to Physician #2 is not the prescribing physician and the prescribing physician #1 would be upset with the attempt to override their orders. Additionally, the CSMDR has a record that a prescription from Physician #1 with the same prescription number as the October through March orders was started on 4/5/25 and is the only Carbidopa medication listed on the CSMDR which kept the order of 2 tabs by mouth 6 times a day. Physician Visit documented on 5/8/25, notes from Physician #3 state R1 was swollen and there was to be an increase in Furosemide. Physician visit note shows Physician #4 on 5/16/25 noted “lasix 40 mg daily”. Furosemide and Lasix are the same medication. The new medication was not filled until 5/16/25 and was not started per the CSMDR until 5/21/25. Per documentation, this is a delay in following doctor’s order for at minimum 12 days and 5 days following receipt of the medication. Continued on 9099C Discussion and review of Facilities Physician Visit notes show that Credible Witness 2 (W2) states on 3/18/25 that resident was observed breathing heavily during a visit. 12/17/24 notes from W2 state R1 was “concerned about medication management by staff. Reporting multiple people giving (R1) medications at inconsistent times.” Interview and record review from staff at facility where R1 transferred on 5/29/25, a copy of the medication release form was provided to LPA. This form lists all medication that came from Lorie’s RCFE and signed off by the responsible party. The form has written quantities appearing to be from Lorie’s staff with 8 of the 18 medications listed having adjusted quantities written in with a plus sign and an added number. Staff at the new facility stated that the medication was counted upon intake and an adjustment to one of the medication counts was noted on their copy of the form. There were four medications noted by Lorie’s RCFE to have a quantity ranging from 165 to 772 pills being sent to the new facility. Administrators claim that family would request leftover medication to be kept due to co-payment needed for each change. LPA review of CSMDR shows the facility would start medications out of date fill order, one instance a medication started in 4/20/25 was filled in 8/7/24, another instance started 4/6/25, was originally filled 10/11/24. It is also noted that RX numbers were opened out of order, even when no change in doctor order is noted. Of the 7 medications reviewed, there are 12 instances where the medication is not listed on the CSMDR record for multiple months, but the MAR provided record that the medication was given during these months. Based on interviews and record reviews, the allegation is Substantiated. The facility failed to maintain accurate and consistent medication records,and based on records delayed implementation of physician orders. Continue 9099-C On the allegation: Facility failed to notify Licensing agency of eviction. LPA discussed with Licensee regarding the requirement to provide Licensing with a copy of eviction notices. Licensee stated they were unaware and would provide a copy of the notice. Notice was emailed to Licensing on 6/6/25. Notice given to R1 was dated 5/1/25 and had an eviction date of 5/30/25. Resident moved out on 5/29/25. Based on the interview and record review, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit. On the allegation: Staff failed to meet resident's medical needs It was alleged the facility failed to meet R1’s medical needs, including concerns related to wound care, incontinence care, use of an inhaler, response to call bells, and feeding assistance. LPA reviewed the facility’s Home Health Documentation Log and interviewed a Home Health agent (W1). Records show that a Registered Nurse (RN) and Licensed Vocational Nurse (LVN) provided wound care and medical oversight on 4/25/25, 4/28/25, 5/1/25, 5/5/25, 5/9/25, 5/12/25, 5/16/25, 5/19/25, 5/21/25, 5/26/25, and 5/29/25. W1 confirmed that nurses’ notes documented wound care, fall prevention education, and management of bilateral edema. W1 stated that no concerns were noted regarding facility staff or care, and staff were described as attentive and caring. Interviews with home health staff confirmed instructions provided to staff were followed regarding wound care. Records reviewed also showed that Speech, and Physical Therapy had visited the resident eight times from 4/25/25 to 5/29/25. Interviews with staff and administrators from both this facility and a subsequent facility where R1 resided confirmed that R1 was able to advocate for their needs. Staff reported that R1 did not always inform them when their brief was wet. One incident was noted where R1 was observed with wet pants, and staff stated R1 had been changed earlier but had not communicated the need for another change. Interview with F1 stated Administrator Claire instructed staff to increase the frequency of checks for R1’s incontinence needs. It was alleged that staff initially used medical tape to treat a skin tear from a fall. F1 stated that Administrator Claire later re-dressed the wound using steri-strips and believed the initial use of medical tape was inappropriate. However, there was no documentation from Home Health or other medical professionals indicating that the use of medical tape caused harm or was improper. It was alleged that R1 was being fed too quickly. F1 stated that Administrator Freda reportedly instructed staff to slow down during feeding. An Occupational Therapist (OT) was brought in to support R1’s independence with feeding. OT notes reviewed with W1 indicated that both staff and R1 demonstrated understanding of feeding instructions. Follow-up visits on 5/13/25 recommended adaptive utensils and plates, with improvement noted. The final OT note on 5/27/25 stated that the goal of independent feeding was “not attained” and that R1 would continue to require assistance. It was alleged staff did not respond to R1’s call bell for their inhaler. Interview with F1 stated while on the phone with R1, R1 needed their inhaler and was told to ring their bell. R1 stated no one responded, so F1 text an administrator to get the inhaler. Per F1, staff were “annoyed” and said R1 would ask F1 for care that was needed, including the inhaler, but did not ask staff for it. Text messages showed multiple occasions where R1 communicated needs to F1, but not to facility staff. Interview with witnesses stated that R1 was hallucinating at night, having night terrors, and increased anxiety. R1 claimed the anxiety was due to no one responding to their calls at night. It was noted on a physician visit on 3/18/25 that R1 was “concerned about breathing – heaviness at night mostly. [R1] is also having increased anxiety due to staff not responding to [R1] call/bell ringing at night.” Per W2 notes, R1 still reported night terrors on 4/8/25. An incident report states on 2/15/25, R1 made a call to 911 claiming another resident was having a heart attack. Emergency personnel showed up and checked on the other resident, and found other resident was asleep and not experiencing any issues. Another incident report on 3/13/25 noted that at 11:10pm during rounds, staff noticed resident was awake, hallucinating, had made a mess of R1’s room and also admitted to calling the facility house phone. The administrator and F1 were notified of this behavior. On this same report, facility states that family instructed staff to take R1’s cell phone at night, and it was stated by family and administrator that R1 was aware and ok with this. Interviews with staff stated they always respond to bells during the day and night, have awake staff at night. LPA verified the bells used was at one time a hand bell and at one time a push button remote bell, both were audible throughout the house. LPA unable to conduct interview with current residents in care due to cognitive concerns. A physician’s report dated 5/15/25 stated that R1 required a higher level of care, specifically Skilled Nursing. The facility issued an eviction notice based on this assessment. Administrators and documentation confirmed that R1 was declining, had increased fall risk, and was resistant to staff education and redirection. A Home Health RN note described R1 as “resistant to education.” The investigation showed the facility attempted to meet R1’s medical care needs, and no concerns were noted in documentation or interviews from medical professionals who treated R1 at the facility. Although the allegation may have occurred or is valid, there is insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit report provided to administrator.