complaint·June 20, 2025

Report Continued from LIC 9099... It was alleged that staff did not ensure injections are administered by an appropriately skilled professional. It was reported that Resident #1 (R1) is prescribed four units of Lantus every 12 hours, administered via an injection pen. However, R1 is unable to administer the injection independently. Interviews conducted with staff and R1 revealed that R1 is responsible for self-administering their medication. R1 stated that facility staff assist by bringing the injection pen to them but confirmed that they perform the injection themselves. During interview, R1 demonstrated to the LPA where and how they administer the injection. Additionally, a review of R1’s physician’s report dated 10/10/2024, lists R1’s primary diagnoses as mild cognitive impairment (MCI) and diabetes. Regarding the diabetes management, the report states that R1 is capable of managing their own treatment, medication, and equipment. Based on record review and interviews conducted, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation, “staff did not ensure injections are administered by an appropriately skilled professional” is deemed Unsubstantiated at this time. It was also alleged that staff are not documenting medications appropriately. It was reported that the medication Lispro is supposed to be administered; however, it is not being documented as administered by facility staff. A review of R1’s medications, the Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that Insulin Lispro, administered via injection pen, is being administered four (4) times per day. Staff interviews confirmed that R1’s blood glucose levels are being checked four times daily and that R1 self-administers their insulin injections. Staff also stated that the MARs are updated shortly after medications are distributed to all residents in the facility. Furthermore, at the time of the visit, the medications appeared to be properly documented on the CSMDR. Based on medication review and record review, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “staff are not documenting medications appropriately” is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was further alleged that Administrator is not competent to meet the needs of residents. It was reported that the Administrator is not properly trained to care for the residents. Interviews conducted with both facility staff and residents revealed that the Administrator is effectively meeting residents’ needs and providing assistance within the facility as needed. Residents stated that the Administrator checks on them daily and also assists with providing care and supervision throughout the day. Additionally, residents did not express any concerns regarding the Administrator's ability to meet their needs during interviews. Furthermore, record review of the Administrator’s personnel file revealed that the required annual training is up to date and that the Administrator’s certificate is valid through 04/06/2026. Based on the information obtained through record review and interviews, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “Administrator is not competent to meet the needs of residents” is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided. Report Continued from LIC 9099... It was alleged that staff did not ensure glucose checks are administered by an appropriately skilled professional. It was reported that R1 is supposed to have their blood glucose levels checked four times a day and at bedtime and the glucose levels are not being documented consistently. Interviews conducted with staff indicated that they assist R1 by bringing the necessary tools to perform glucose testing. Staff reported that R1 pricks their own finger and that they only provide the blood glucose meter for R1 to place the blood sample. Staff also stated that they document the glucose readings each time they are checked. However, during an interview, R1 confirmed that their blood glucose levels are checked at least four times a day but stated that facility staff perform the entire process by bringing the meter, pricking their finger, and documenting the results. At this time, R1 also noted that staff inform them of the glucose readings after each test. Furthermore, record review of R1’s physician’s report dated 10/10/2024, indicates under mental condition that R1 is not confused or disoriented. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure glucose checks are administered by an appropriately skilled professional” is deemed Substantiated at this time. It was also alleged that resident missed medication due to staff not ordering medication. It was reported that a medication list was emailed to the Administrator; however, the medication had not been ordered by the facility. A review of R1’s medications, Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that R1 has not been receiving their medication as prescribed, as the medication ran out before a refill was received from the pharmacy. Interviews conducted with staff revealed that they notify the Administrator before medications run out; however, the refills do not always arrive on time from the pharmacy. As a result of not having the medication refills available, R1 has had missed doses. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “resident missed medication due to staff not ordering medication” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. There is a $250 civil penalty due to repeat violation of Section 87465(a)(4) as it has been cited previously within the last 12 months. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.