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13 | On September 9, 2024 at approximately 02:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA met with Administrator, Keila O'Farrell.
During the course of the investigation, LPA reviewed resident records, interviewed the former resident and staff. In addition, LPA made observations and toured the facility on July 15, 2024.
Complaint alleges that Medication left accessible to resident in care. Based on the interviews that were conducted, LPA received inconsistent statements and could not corrborate the allegation. Furthermore, during an interview with Resident #1, LPA learned that the facility dispensed medication to Resident #1 and does not recall medications being left in the room.
Complaint alleges that Facility ran out of medication for resident. Based on the interviews that were conducted with staff and Resident #1, (Report continued on LIC 9099C) |
| Unsubstantiated | Estimated Days of Completion: |
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13 | On September 9, 2024 at approximately 02:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hilltop Springs Senior Living for the purpose of delivering complaint findings. LPA met with Administrator, Keila O'Farrell.
During the course of the investigation, LPA reviewed resident records, interviewed the former resident and staff. In addition, LPA made observations and toured the facility on July 15, 2024.
Complaint alleges that Medication not administered per MD orders. Based on interviews that were conducted with the nurse on July 15, 2024 at approximately 02:55 PM, LPA received consistent statements which meets the preponderance of evidence standard. During a review of the Medication Administration Record (MAR) for the medication in question, LPA observed the Medication Administration Record (MAR) for December 26, 2023 and December 28, 2023 and learned that the medication was missed for that resident during those dates. (Report continued on LIC 9099C) |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/10/2024
Section Cited
CCR
87465(a)(6) | 1
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7 | 87465(a)(6):
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement was not met as evidenced by: | 1
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7 | Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring
that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future
compliance. |
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14 | Based on an interview with the Nurse, LPA received consistent statements as it relates to the medication not being administered per MD orders. Furthermore, during a review of the Medication Administration Record on July 15, 2024, LPA observed that medication administration was missed on December 26, 2023 and December 28, 2023 for Resident #1 which presents an immediate health, safety and personal rights risk to the residents in care. | 8
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14 | POC Due Date: September 10, 2024 |
Type B
09/17/2024
Section Cited
CCR
87211(a)(d) | 1
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7 | 87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement was not met as evidenced by:
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7 | Licensee shall submit an LIC 9098 understanding of the regulation and conduct staff training as it relates to ensuring
that Title 22 regulations are being followed at the facility. Furthermore, Licensee shall submit a plan for future
compliance. |
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14 | Based on an interview that was conducted with the Nurse on July 15, 2024, the Department received no incident report for a reportable incident which presents a potential health, safety and personal rights risk to the residents in care. | 8
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14 | POC Due Date: September 17, 2024 |
NARRATIVE |
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32 | LPA received inconsistent statements and could not corroborate the allegation. Furthermore, during an interview with Resident #1, LPA learned that the facility filled the script timely when it was ready by the pharmacy.
Complaint alleges that Resident was found sleeping on soiled sheets. Based on an interview that was conducted with Resident #1, LPA received inconsistent statements. Furthermore, during a tour of the facility on July 15, 2024, LPA observed residents to be appropriately dressed and free from continence. Facility and the resident bedrooms were found to be clean. LPA toured a sample of resident bedrooms which were observed to be appropriate and smelling good.
Complaint alleges Resident fell and was not checked on after the fall. Based on an interview that was conducted with Resident #1, LPA received inconsistent statements as it relates to the allegation. Furthermore, Resident #1 acknowledged of falling and being checked on by facility staff after the fall occurred.
Complaint alleges that Resident was over-charged. The Department's Auditor from the Investigations Branch reviewed the allegation and associating documents which includes the billing related to the allegation and found that the resident was not overcharged for the care and services that were being provided by the facility. The report also noted that the resident received a refund after discharge due to the rent being paid in advance.
Complaint alleges Facility staff falsified documentation. Based on interviews that were conducted, LPA received inconsistent statements. Facility staff have denied falsifying documentation. In addition, during a review of Resident #1's record, LPA reviewed documents and could not find any evidence that the facility was falsifying documents.
A finding that the complaint allegations of Medication left accessible to resident in care, Facility ran out of medication for resident, Resident was found sleeping on soiled sheets, Resident fell and was not checked on after the fall, Resident was over-charged and Facility staff falsified documentation are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. |