It was alleged that staff did not meet resident’s toileting needs. It was reported that Resident #1 (R1) had multiple Urinary Tract Infections (UTI’s) and had been hospitalized due to lack of care from staff. Records review and interviews conducted revealed R1 moved into the facility on 09/30/2023. R1’s physician report, dated 09/29/2023, listed R1’s primary diagnosis as dementia and second diagnosis as ataxia. R1 was identified as being confused/disoriented with inappropriate, aggressive, wandering, and sundowning behaviors and was able to follow instructions; however, R1 was not able to communicate their needs. The report indicated R1 was not able to bathe, dress/groom, or take care of their toileting needs without having someone to assist. Home Health records reviewed revealed that R1 was admitted to the hospital on 10/13/2023 due to altered mental status. After tests conducted, it was revealed that R1’s agitation was due to a urinary tract infection (UTI) and later on discharged back into the facility on 10/17/2023. Further records reviewed revealed R1 had also been admitted to the hospital on 11/01/2023 and 11/14/2023; however, diagnosis for these two (2) visits did not include UTI as a cause. Interviews conducted with staff revealed that status checks are conducted on incontinent residents every two (2) hours unless they need it more often. Additionally, staff stated that they check on the residents assigned to them at the start of their shift and about three (3) times during their entre shift. Per resident notes, it indicates that staff was checking in on R1 and Resident #2 (R2) every morning to assist with dressing and then help escort to the dining room. Interviews with residents revealed that staff often check on them throughout the day and reported having no concerns while living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to supports the allegation. Therefore, this allegation is being deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

Exit interview conducted. Report was reviewed and a copy issued.

It was alleged that staff mismanaged resident’s medication. It was reported that staff provided an incorrect list of medications list to medical providers. Records review of R2’s centrally stored medication and destruction record (CSMDR) it listed all medications the facility obtained when R2 was admitted to the facility. Per R2’s medication clarification, the facility did not have a doctor’s order for medication Carbidopa-Levodopa 25 – 100mg; therefore, the facility faxed R2’s Primary Care Physician (PCP) requesting to review the medications list and clarify the dosage and frequency of medication. Although the facility reached out to R2’s PCP regarding R2’s medications on 10/05/2023, the facility did not update R2’s medications list before providing it to the hospital after R2 was sent out a week later. Furthermore, per medication of three (3) randomly selected residents it was revealed that facility is receiving resident’s medication; however, the staff are not documenting the medication on the CSMDR when it is received. Staff interviews revealed that personnel in charge of medications continuously changes which may be the reason why medications are not being properly documented on resident’s CSMDR. Additionally, two (2) out of three (3) CSMDR reviewed did not have medication information such as filled date and start dates up to date. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to say, “staff mismanaged resident’s medication”. Therefore, this allegation is being 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. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.