complaint·July 15, 2025

Continued from LIC9099... S1 then left a note for Staff 2 (S2) to follow up with R1’s physician. There are no records of S2 following up. S1 stated that medication was held until orders could be obtained. On 5/28/2025, an interview with R1’s treating physician revealed that R1 was in stage four terminal heart failure and had pneumonia. Additionally, the physician stated that they did not believe that the medications in question would have changed R1’s terminal prognosis. However, during today’s complaint investigation visit, an interview with Staff 3 (S3) revealed that no log was maintained showing staff observed R1 for swelling or other symptoms of fluid retention. Based on interviews and record review, the facility was unable to provide proof that staff followed through with obtaining blood pressure parameter orders or that staff dispensed medications as prescribed, (see LIC9099D). Based on interviews conducted and records obtained, the allegation that the facility staff did not dispense medications as prescribed is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.