complaint·May 29, 2025

On the allegations Staff mismanaged residents’ medications, Facility staff failed to notify resident and responsible party, Staff did not respond to resident's call button in a timely manner the following was found: On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R2 MAR where medication was marked as administered however R2 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight. On 5/14/2025 LPA also tested the call buttons in memory care and found that the systems to notify staff of calls are not properly working. Memory care coordinator states that they are actively working towards a solution and are currently training staff on how to ensure residents safety without call buttons.On 5/29/2025 LPA tested the call buttons in the room which was occupied by R1. LPA found during the test that the call button in the bathroom was not operational. The ED was not aware that the call button did not work and did not have a work order for it to be serviced. On 12/09/2024 LPA reviewed interviewed ED . ED states that the prior Health and Wellness Director (HWD) would change the residents needs and services and that they would receive the care but that the families were not aware of the cost associated with the care. The ED states that because of the discrepancy they have reimbursed credits. ED states that HWD resigned when confronted with the discrepancy. It was also found before the HWD resigned that reports were not being reported as required. ED states that there were instances where residents care plan did not match the care they needed or did not require. Report continues on LIC9099-C Pg 3 Based on interviews, record reviews, and observations the allegations Facility is in disrepair, Staff are not following the residents care plan, Facility does not send incident reports as required, and Staff are not providing medication as prescribed is SUBSTANTIATED . Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report provided.