Complaint Investigation Report

On 04/24/2026 LPA obtained a copy of a video of a specialty device system discarded in a garbage can and improperly set up per witness (1) W1. An interview with W1 indicates the speciality device was improperly set-up and discarded when staff could not facilitate proper use of the device. In addition, LPA obtain a photo on 05/21/2026 of the Resident end of the same device in a trash can and on 05/22/2026 LPA obtained a second photo of the collection side of the same device improperly set up. In an interview with staff member S3, S3 indicated that some of the staff applying the speciality device to R1 were “not trained” in use of R1’s specialty device, and that a private caregiver of R1 had written down the exact details of how to apply the device. An interview with staff member S1 indicates they had personally learned how to apply R1’s medical device from a hospice nurse not employed by Ivy Park, (rather than through an inservice provided at Ivy Park at Rockville) A similar interview with staff member S2, had S2 saying that the use of R1’s medical device was a particularly private and invasive procedure and as such would not have be acted out or demonstrated with new staff in front of R1. When S2 was asked, “Does your team (at Ivy Park) have written step-by-step instructions on how to apply the specialty device to R1 or how to help R1 use their CPAP and if the trainings were documented", S2 offered, “It is not something we typically see a lot of, again it would be shadow training or R1’s private caregiver explaining how it is done. The training is not documented”

Because photos and a video obtained by this LPA demonstrate the improper set-up of R1’s medical device and because no evidence of staff documented training in the application or use of the speciality device could be obtained at the time of the investigation, the preponderance of evidence standard has been met, therefore the above allegation of “staff are not adequately trained” is found to be SUBSTANTIATED.

A type B citation for violation of CCR 87468.2(a)(4) which requires caregivers to be competent in the care they provide is being sited. See 9099-D page.

In addition, on 03/25/2026 CCL received a complaint alleging that staff at Ivy Park at Rockville failed to ensure PRN and prescribed medicines were dosed and administered properly. An interview with R1 revealed that they had long received the incorrect dose of their prescribed medicine and once the dosage was corrected, a long term health concern of theirs improved.