complaint·April 29, 2025

LPA Urena met with Kenneth Mahler, Administrator, and Gloria Morales, Associate Administrator and explained the reason for the visit. The LPA advised the Administrator that the case was referred to the Community Care Licensing (CCL) Investigations Branch (IB). At 11:31am, the LPA requested documents pertinent to the investigation. The LPA determined further investigation was needed prior to issuing findings. On 03/17/25, LPA Cortez, interviewed seven (7) staff, three (3) residents and observed activities and lunch in Memory Care. On 04/24/25, LPA Cortez interviewed one (1) staff, three (3) residents, three (3) resident's family members and/or their authorized person, observed dinner in Memory Care, conducted a file review and collected pertinent documents relevant to the investigation. During today's visit, LPA Cortez conducted two (2) staff, one (1) resident, and two (2) resident family members interviews, observed resident activities, lunch and dinner being served. Investigator Hector conducted interviews on 06/05/2024, from 12:50pm to 2:44pm, with Physician’s Preferred Hospice Care nurse, Administrator, and lead med tech; on 06/07/2024, at 3:38pm, with Associate Administrator; on 06/13/2024, at 11:18am, with Ararat Plaza Pharmacy Pharmacist; and on 06/14/2024, at 4:44pm, with Physician’s Preferred Hospice Care Case Manager. In addition, the investigator reviewed Community Memorial Hospital (CMH) medical records, Los Robles Regional Medical Center records, and facility file documents related to R1. A review of R1’s Physician Report, dated 03/24/2023, listed the primary diagnosis as Alzheimer’s Disease with late onset. The report also indicated R1 was on hospice due to the diagnosis. According to the facility timeline report, R1 was given their remaining medication when R1 went out of town with family on 03/29/2024. Since 3/30/2024, and 03/31/2024, was the Easter holiday weekend, the facility gave R1 and R1’s family, the remaining tablets of Triamterene. R1 left the facility to spend time with family during the holiday weekend. The timeline report lists that facility staff attempted to obtain a refill of medication starting on 04/01/2024. The report documents the Med-Tech called the hospice company, unable to reach, then called R1’s resident representative to notify they were unable to reach hospice for the refill. The staff also called and spoke with the hospice nurse on 04/02/2024, and 04/04/2024. On 04/04/2024, R1 was documented as being “out of breath” and was taken to the hospital the following day. Report will continue on LIC9099-C, 3rd page. On 04/05/2024, contacted hospice again regarding the refill. On 04/09/2024, the hospice nurse stated they had already refilled (Triamterene medication) and had placed an order already. On 04/11/2024, the Associate Administrator spoke with the Pharmacist who advised there was an error with how the facility was documented in their records. This error caused a delay in the medication delivery to the facility. A review of the CMH medical records documented R1 was admitted to the hospital on 04/05/2024, with an Admission Diagnosis of Congestive Heart Failure Exacerbation. The history also documented that R1 “presented with shortness of breath”, which was also the Chief Complaint. The patient history listed that R1 had “been having increased shortness of breath as well as leg swelling and heaviness” for the “last 3 days.” Emergency Medical Services (EMS) was contacted two days prior for the same issue. The records state that R1’s “oxygen saturations were low but that they were still functioning well and as such they were not taken to the hospital.” The records confirmed R1 was “positive for extremity swelling” according to the cardiovascular assessment. The Physical Exam noted that R1 had “1+ pitting edema in the bilateral lower extremities.” The medical records noted that R1 developed “delirium and agitation, and R1’s resident representative requested discharge back to the assisted living facility where R1 lives. R1’s agitation was believed to be secondary to change of environment in the setting of dementia.” R1 was discharged back to the facility on 04/07/2024 to resume previous hospice care. During the Department’s investigation, the investigator reviewed records, interviewed facility staff, and interviewed hospice agency staff. The facility staff claimed they made several attempts to contact the hospice agency for the medication refill. The Hospice agency staff denied receiving contact until the medication was refilled 04/11/2024 (the medication ran out at the end of March 2024). However, the hospice agency case manager confirmed receiving contact from R1’s daughter on 04/01/2024, regarding the care of R1. This contact is consistent with the timeline provided by the facility that they asked R1’s resident representative to ask the hospice agency for a medication refill. There is not sufficient evidence to support the allegation of neglect regarding the staff’s efforts to refill R1’s medication . Therefore, the allegation “Neglect/Lack of Supervision: Facility staff did not dispense medication for Resident #1 (R1) which resulted in hospitalization” is deemed Unsubstantiated at this time. Report will continue on LIC9099-C, 4th page. On the allegation, “Facility staff did not supervise residents resulting in residents eloping”; it is the concern of the reporting party that Memory Care residents including Resident #1 (R1) have gotten out of the facility through secure doors to the street or front of the building in 2023 and 2024. Various residents’ names (incomplete) and dates were given of when residents have eloped from the facility. Staff interviews revealed that they have no knowledge of the residents that were named to have eloped from the facility, and that if any resident did elope, they were aware of the protocol to follow. Staff would follow the resident, and re-direct them back to the facility, if the resident eloped and staff was unaware, they would go out searching for the resident, contact 911, and their responsible person, as well as report it to licensing. Three residents’ family members/authorized persons, two of which where the authorized person of two of the residents that were named to have eloped, revealed that they do not have any concerns of the residents eloping, and have not been notified of any elopement incident. File review revealed that in 2023 two residents eloped or attempted to elope from the facility, and the community self-reported one of the incidents to CCL and CCL issued a deficiency for the other incident. During today’s visit the LPA tested the delayed egress in one of the Memory Care’s exits at 1:10 p.m. and the alarm went off, three staff came rushing to the exit door and arrived by 1:12 p.m. Based on the information obtained and reviewed, there is insufficient evidence to support the allegation on “Facility staff did not supervise residents resulting in residents eloping”. Therefore, this allegation is being deemed Unsubstantiated at this time. On the allegation, “Facility staff spoke inappropriately to resident”; it is the concern of the reporting party that staff belittle and taunt a man who had a UTI and was acting erratic. Names of resident and staff was not provided. All staff interviewed denied ever speaking inappropriately to any of the residents and denied witnessing any other staff speaking inappropriately to any of the residents. All residents interviewed denied ever being spoken to inappropriately. Furthermore, interviews with residents’ family members/authorized persons revealed that they have never witnessed residents being spoken to inappropriately. Based on interviews, there is insufficient evidence to support the allegation that “Facility staff spoke inappropriately to resident.” Therefore, the allegation is being deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.