complaint·April 17, 2025

(Page 2) Report Continued from LIC 9099... During today’s visit, starting at 9:32 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:00 a.m., LPA conducted in person interviews with three (3) residents and the Administrator, a file review, medication audit and collected documents pertinent to the investigation. On the allegation Staff is administering a non-prescribed medication to a resident in care it is the concern of the reporting party (RP) that the facility staff administered Hydrocodone to Resident #1(R1) without a prescription. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator, three (3) residents, a file review of documents pertinent to the investigation for R1 and medication audit on all current residents. R1 has passed away and all medications were properly destroyed and documented therefore no medication for R1 was available. File review of documents pertinent to the investigation for R1 revealed that that R1 was not prescribed hydrocodone nor was it listed on R1’s centrally stored medication record (CSMR) or on the medication administration record (MAR). Interview with staff revealed that R1 was not on Hydrocodone. Staff did not administer Hydrocodone to R1. Staff do not administer non-prescribed medications to their Residents. Interview with the Administrator revealed that R1 was not prescribed Hydrocodone. They did not administer Hydrocodone to R1. They do not administer non-prescribed medications to their Residents. Interviews with Residents revealed that they are familiar with the medications they take. They have not had any discrepancies or concerns with medication management at the facility. Medication audit revealed that medications are securely stored in a locked cabinet located in the kitchen. At 12:02 p.m., LPA reviewed medications for five (5) residents. All medications observed were labeled, stored, and properly documented at the time of the visit. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff is administering a non-prescribed medication to a resident in care is deemed unsubstantiated at this time. On the allegation Staff are not following physician's orders it is the concern of the reporting party (RP) that the facility staff did not follow physician orders for R1 to receive breathing treatment every day. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator and a file review of documents pertinent to the investigation for R1. R1 has passed away and is no longer available to provide an interview.File review of documents pertinent to the investigation for R1 revealed that R1 was prescribed DUONEB (Iprat-Albut) on 06/24/2025 instructing the “use 1 vial via nebulizer 3 times daily routine”. Report Continued on LIC 9099-C Page 3... (Page 3) Report Continued from LIC 9099-C Page 2... R1’s MAR indicates that R1 received treatment as prescribed three (3) times daily. Interviews with the staff revealed that R1 received breathing treatment as prescribed three (3) times daily. Staff ensured that R1 received breathing treatment as prescribed. The staff followed physician orders and gave R1 breathing treatments as prescribed. Staff do not violate physician orders. The staff have never not followed physician orders. Interview with the Administrator revealed that R1 received breathing treatment as prescribed three (3) times daily. The staff would ensure R1 received breathing treatment as prescribed and document it on the MAR. They do not violate physician orders, and they have never not followed physician orders. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation Staff are not following physician's orders is deemed unsubstantiated at this time. On the allegation Staff left resident in a wheelchair for a long period of time it is the concern of the reporting party (RP) that the staff left R1 in a wheelchair for a long period of time because staff were unable to transfer R1. To investigate this complaint, LPA conducted in person interviews with five (5) staff including the Administrator and three (3) residents of which two (2) are wheelchair users. R1 has passed away and is no longer available to provide an interview. Interviews with staff revealed that R1 had expressed body weakness and unwillingness to ambulate and preferred to stay in a wheelchair. Staff would encourage and assist R1 at time with ambulating in a walker around the facility. Staff did not leave R1 in a wheelchair for a long period of time. Staff were always able to assist and transfer R1. When R1 had body strength they required one (1) staff assistance when transferring. When R1 expressed body weakness R1 required two (2) staff assistance when transferring. Interviews with the Administrator revealed that R1 had frequently expressed body weakness and unwillingness to ambulate. R1 preferred to stay in a wheelchair however Staff would often encourage and assist R1 with ambulating in a walker around the facility. They did not leave R1 in a wheelchair for a long period of time. They do not leave their residents in wheelchairs for a long period of time. They encourage residents to walk around the facility. Staff were always able to assist and transfer R1 when needed. Staff are always available to assist transferring residents. Interviews with residents revealed that they are not left in a wheelchair for a long period of time. Staff assist and encourage the residents to walk around the facility with their walkers if possible. Staff assist with transferring when needed and requested. Residents have no concerns with the care that is provided to them. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation Staff left resident in a wheelchair for a long period of time is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.