complaint·June 13, 2025

Regarding the allegation: 1.) Facility staff did not properly assist resident with self-administration of medications as prescribed. On 06/10/2025, the Department received a complaint alleging staff not properly assisting Resident #1’s (R1’s) with the self-administration of R1’s liquid Escitalopram medication as prescribed. During today’s visit, the LPA reviewed R1’s records including but not limited to progress notes, Medication Administration Record (MAR), and resident appraisal. Per R1’s prescription order, on 04/22/2025, R1 was prescribed Escitalopram 5mg/ 5mL oral solution (Lexapro) to be taken 10 mL (10 mg) by mouth daily. Interview with the Wellness Director, Jessica Saks revealed that on 05/10/2025, she conducted an audit on R1’s medication. Upon the audit, it was revealed that Staff #1 (S1) did not properly assist R1 as S1 prepared and gave R1 5mL of Escitalopram oral solution instead of the 10 mL as prescribed. Jessica S. explained that S1 admitted to the medication error and has since been removed as a medication technician. Jessica S. stated that an exact date of the medication error was not given but believes that the error occurred between 04/24/2025 and 04/26/2025. Jessica S. stated that they self-reported the medication error to Community Care Licensing on 05/15/2025. Jessica S. explained that an in-service medication training was held on 05/10/2025 with staff regarding medication procedures and protocols. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Facility staff did not properly assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time. Regarding the allegation: 2.) Reporting requirements are not being met. It was alleged that the facility staff failed to report all of Resident #1’s (R1’s) medication refusals to R1’s responsible person. Interview with the Wellness Director, Jessica Saks revealed that facility staff do and are supposed to communicate with families or responsible persons and doctors when a resident refuses medications or care. Per record review, and interview R1 refused Escitalopram 5mg/ 5mL oral solution on 05/07/2025 and facility staff did not report the refusal to R1’s responsible person. The LPA reminded the ED and Jessica S. that facility staff should be reporting any incident which threatens the welfare, safety or health of a resident such as refusal of medication. The LPA also reminded Jessica S. and the ED that facility staff should be documenting their efforts and form of communication with families, responsible persons and doctors. Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation, “Reporting requirements are not being met” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.