Complaint Investigation Report

A review of the records and interviews concluded that the condition of Resident 1 (R1) was re-assessed by their primary care physician to have evolved to require assistance in the time period between yearly evaluations dated June 20, 2019 and August 20, 2020. The initial report indicates that the resident is noted as being able to self-administer their medication without supervision. The following physician report indicates however that the resident is no longer able to self-administer without supervision.

Despite this change in condition, the resident was not transitioned to medication management status by the facility and formally assisted by facility staff until December 11, 2021 as documented in staff interviews as well as in printouts from the Medication Administration Records provided by the facility. While staff interviews evidenced that there is normally a process for such orders to be documented and the necessary changes implemented, it appeared during the investigation that it had not been the case as far as the care for resident R1 was concerned. These elements confirm that the resident was left to manage her own medication with no formal assistance by the facility for a period of 16 months after a transition to Medication Management was ordered by the physician.

During a visit conducted on February 17, 2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch was provided R1's file to review. Based on observation, LPA was able to determine that the resident R1’s file did not include the original signed Admission Agreement. Facility administrator confirmed that he was unable to locate the Admission Agreement either in paper or electronic form. A deficiency for this was already cited on April 21, 2022.

Based on the evidence gathered during the investigation, the three allegations listed above are deemed to be substantiated, meaning that the preponderance of evidence standard has been met. Cited deficiencies per Title 22 Division 6 of the California Code of Regulations are detailed in the attached form LIC9099-D.

An exit interview was conducted with the facility representative and a copy of this report along with appeal rights were left at the facility.

This report was amended to correct a technical error regarding the visit type. This was a complaint visit.