Complaint·April 8, 2025

Allegation: “Administrator did not ensure resident’s medications were available:” The complaint alleges that on 02/05/2025, medications were delivered for Resident #1 (R1), however medications were not provided to R1 nor their hospice care provider. LPA reviewed hospice plan of care, medications and medication orders for R1, as well as interviewed staff and Administrator related to this allegation. Administrator indicated R1’s outside medical provider did not inform the facility of a change in R1’s care plan. LPA reviewed R1’s hospice plan of care and confirmed these medications were not included in the care plan on file at the facility, which was dated 11/07/2023. However, interview revealed that Administrator called and spoke to R1’s family member who verbally confirmed there had been a change in R1’s plan of care, additional medications were prescribed by R1’s doctor, and the medications were authorized by R1’s family member. Interview revealed that the 2 (two) medications in question were delivered to the facility between 10:40-11:00PM on 02/05/2025. Staff signed for the medications and contacted the Administrator. Administrator instructed staff to place the medications in the refrigerator. Although the medications were not listed on the plan of care on file at the facility, facility staff still signed for the medications and centrally stored these medications per the Administrator’s instructions. Additionally, R1’s hospice nurse was present in R1’s room at the time of delivery, however facility Administrator nor staff informed R1’s hospice nurse that the medications were delivered and available to be administered. Interview revealed that at 10:00AM, a different hospice nurse arrived to take over R1’s care. This nurse requested R1’s medications and facility staff provided the medications to the hospice nurse at 10:16AM, which is almost 12 (twelve) hours after the medications had been delivered. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “administrator did not ensure resident’s medications were available” is deemed SUBSTANTIATED at this time. Allegation: “Administrator speaks inappropriately in the presence of resident in care:” It was alleged that on 02/05/2025, the Administrator arrived at the facility, entered R1’s room, and was raising their voice at R1’s outside medical provider. Interview revealed that facility staff had noticed a rapid decline in R1’s health condition and facility staff had contacted the facility Administrator to inform them of this observation. Facility staff then contacted R1’s hospice care provider to inform them. Hospice staff arrived at the facility to assess R1’s changing needs and with R1/their family member’s consent, hospice staff remained at the facility to provide additional care to R1. Administrator arrived at the facility that afternoon and entered R1’s room. Interview with Administrator revealed the hospice agency had not communicated the change in Report Continued on LIC 9099-C plan of care to the Administrator and therefore, the nurse should not be present in the facility and further, Administrator needs to know who is coming to the facility and when. However, the facility’s visiting policy in R1’s signed Admission Agreement indicates facility visiting hours are from 09:00AM to 06:00PM daily and resident personal rights indicate residents have a right to visit privately without prior notice. Administrator admitted having the conversation with the hospice nurse while both parties were in R1’s room, with R1 present. Telephonic witnesses confirmed the conversation was “heated” and Administrator stated to LPA that he was upset that hospice had not informed him. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “Administrator speaks inappropriately in the presence of resident in care” is deemed SUBSTANTIATED at this time. Allegation: “Resident was charged for services not agreed upon in the care assessment:” It was alleged that after R1 had fallen at the facility, the Administrator informed R1’s family that R1 required a 1:1 caregiver at an additional cost, however this was not agreed upon nor indicated in R1’s assessment. LPA reviewed R1’s admission agreement signed on 12/15/2021 when R1 moved into the facility. Admission Agreement states “if the facility rates for basic services change because the resident’s needed/desired services change, a written notice will be provided to the resident and the resident’s representative within two (2) business days of providing service at a new level of care.” However, there was no new care plan completed at that time, indicating the need for increased supervision and a change in level of care. No new Physician’s Report was filled out either, which is also required for a change in condition. Hospice plan of care dated 11/07/2023 states resident is “ambulatory: requires walker. Maximum assist,” however it does not indicate 1:1 supervision is required. Staff interviewed indicated they believe there was a verbal agreement with R1’s representative related to the additional care, as R1 had a diagnosis of dementia, had broken their leg, and needed additional supervision to remind R1 not to get up and re-injure their leg. LPA requested proof of written notice or signed new care plan following R1’s fall, however nothing in writing was provided by the licensee. R1’s representative stated they did not receive such written notice, but was charged in excess of $17,000 for additional care. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation above is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of today’s reports and appeal rights were provided.