Complaint Investigation Report

[CONTINUED FROM LIC 9099] R1 was not interviewed for this case because they had moved out of the facility by the date CCLD received the complaint, and then R1 passed away under hospice care, from their Alzheimer’s Disease, just two days later. Multiple family members unanimously reported that R1 could not be meaningfully interviewed during their final days.

LPA reviewed the hospice medication orders regarding R1’s ABH gel, which were signed and in Licensee’s possession, and the facility’s Medication Administration Records (MARs) on R1, showing when staff applied the ABH gel to R1’s skin, in practice. Together, these documents showed:

From 03/20/2026 through 03/31/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 8 hrs. routinely or every 4 hrs. as needed,” when in reality, R1’s hospice doctor had ordered the ABH gel to be given every 8 hours routinely, and additionally up to once every 4 hours as needed. In practice, staff applied the ABH gel to R1’s skin 2 times on 03/20/26, 1 time on 03/21/26, 2 times on 03/22/2026, 1 time on 03/25/2026, 1 time on 03/26/2026, 1 time on 01/29/2026, and 2 times on 03/31/2026. There were 26 missed routine doses of the ABH gel between 03/20/2026 and 03/31/2026.

Then from 04/01/2026 through R1’s move-out on 04/04/2026, facility staff wrote in the MAR that the ABH gel should be applied to R1’s skin “every 4 hours routinely topical for agitation,” consistent with a changed/updated hospice order executed around that time. However, in practice, staff applied the ABH gel to R1’s skin 1 time on 04/03/2026 and 2 times on 04/04/2026. There were thus 18 missed routine doses of the ABH gel between 04/01/2026 and R1’s physical move-out around midday on 04/04/2026.

Review of R1’s hospice agency’s visit records showed multiple of their nurses wrote that facility staff were not giving R1 their ABH cream as ordered, despite their giving corrective instruction. LPA’s interviews of multiple facility medication technicians showed they lacked clarity and consensus on the matter, and corroborated that the ABH gel was not given to R1 exactly as it was prescribed during the complaint period. Manager interview showed that during the complaint period, there was an unplanned staffing vacancy at the Resident Services Director (RSD) role, and there was no licensed nurse or pharmacist active on the staff roster. (This point is already being addressed in a separate Annual Inspection report.) The RSD is ordinarily the facility’s lead clinician who oversees the facility’s medication management program.