Complaint Investigation Report

Furthermore, according to medical documents reviewed, on 12/27/22, R2 was transported to CPMC for suffering possible seizure, however R2’s doctors believed R2 was having an overdose on fentanyl rather than having a seizure which the facility stated. R2 was found to test positive for fentanyl and benzodiazepine on a urine drug screen.

Based on observations, interviews conducted, and documents reviewed during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that residents overdosed on drugs is determined to be SUBSTANTIATED as the Licensee/Administrator admitted he was aware that residents were using drugs in the facility, however failed to take action or provide additional supervision to the residents in care.

Regarding the allegation that facility failed to report incident to CCL, according to the reporting party, R1 was hospitalized on 12/29/22 and R2 was hospitalized on 12/27/22 as one had a seizure and the other resident couldn’t breathe. In addition, the reporting party indicated, he/she is unsure if the facility reported this incident to CCL.

During the investigation, LPA requested copies of the incident reports that were submitted to CCL with the fax confirmation sheet. Based on the incident reports reviewed, on 12/29/22, R1 was hospitalized due to not being able to breathe. Licensee did not submit an incident report for R1 till 1/12/23 when LPA requested for it. In addition, on 12/27/22, R2 was hospitalized due to a seizure. Licensee failed to submit an incident report till 1/12/23 when LPA requested for it.

Based on information collected and documents reviewed during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that facility failed to report incident to CCL is determined to be SUBSTANTIATED.

Regarding facility staff took resident’s money, according to the reporting party, Staff 2 (S2) wire transferred Resident 3’s (R3’s) money into S2’s bank account.