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32 | R1 did not receive the nasal spray for a total of nine (9) days from 08/01/2025-08/10/2025. However, the facility made multiple attempts to receive the medication. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure resident received prescribed medication” is deemed UNSUBSTANTIATED at this time.
Lastly, it was alleged that on 08/28/2025, R1 had a confirmed outing to a hair salon with the facility’s transportation but was then left in the heat for 2 and a half hours with no ride back and the facility not answering R1’s/responsible party’s calls. LPA reviewed the employee timecards for 08/28/2025 and observed that both drivers were clocked out of their shifts by 04:33PM. Staff interviews confirmed that the drivers are either scheduled from 8AM-04:30PM or 07:30AM-4PM. LPA interviewed staff who stated that R1 notified them of their appointment shortly before their hair appointment at 2PM on 08/28/2025. R1 and responsible parties were informed that the facility can accommodate the ride to the salon, however, the drivers will be done with their shifts by 04:30PM and that they will not be able to drive R1 back to the facility if the appointment finishes after that time. Around 04:53PM the facility received a call from R1’s responsible party stating that R1 has been waiting in the heat and no one has picked R1 up. The facility ordered a Lyft to R1’s location at 04:56PM with a note to the driver that R1 “is at the hair salon.” The facility attempted to call R1 and R1’s responsible party to inform R1 that the Lyft driver had arrived, but was unable to get a response. The Lyft driver waited at the location until 05:10PM and cancelled the ride due to “rider no-show.” At 05:51PM, the facility ordered another Lyft with the same note to driver, however, the driver cancelled the ride at 06:02PM for “rider no-show.” After the second cancellation, Administrator Lourdes Bustamante drove to R1’s location and picked R1 up. R1 was back at the facility around 06:10PM, approximately 1 hour and 15 minutes from the first Lyft order at 04:56PM. LPA reviewed call logs of the facility’s drivers, R1, and concierge. There were no missed calls observed on 08/28/2025 to either driver. R1’s call logs had no record of calls made to the facility on 08/28/2025, however, there were six (6) missed calls from the facility to R1 between 05:53PM-05:59PM on 08/28/2025. The facility received a call from R1’s responsible party around 04:53PM and the Lyft order was subsequently placed. LPA did not observe missed calls to the concierge.
Report Continued on LIC9099-C. |