Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Deficiency on 05/16/2025, stemming from subsequent complaint investigation (Control Number: 28-AS-20250429162024) visit on 05/16/2025. LPA was greeted by Director of Nursing- Deseree Suyat and explained the purpose of the visit.

On 05/16/2025, LPA Ramirez conducted additional staff interviews regarding the above complaint investigation. During staff interviews, staff revealed resident#1 (R1) will at times refuses to take their medications due to the taste of the pills. Staff revealed when R1 is hesitant or refuses to take their medication, staff will camouflage R1’s pills into chocolate pudding and feed it to R1. During records review of R1’s file, it revealed R1 cannot determine their own need for prescription and non-prescription PRN medication but can communicate their symptoms indicating a need for a nonprescription medication. Records reviewed revealed, R1 suffers from cognitive impairments. Per Title 22, Division 6, Chapter 8, Article 08. 87465 (a)(5)(D)- Incidental Medical and Dental Care- (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: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.

Based on staff interviews and records reviewed, R1’s medication was camouflaged into pudding by staff without R1’s consent or a physician’s order, this poses an immediate risk to the health, safety, or personal rights of persons in care. LPA Ramirez will issue a one (1) Type A deficiency. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.