complaint·October 15, 2025

On the allegation that staff provided unprescribed medication to residents (R1) in care; it is the concern of the reporting party that staff used medication which was not prescribed to R1, and that the medication belonged to another resident. To investigate the allegation, LPA Urena interviewed the RP on 10/13/2025 at approximately 11:47 a.m. Per the RP, the staff administered medication (two dosages of Lorazepam) which could have had severe complications given that R1 has dementia. LPA Urena interviewed R1’s responsible party and the interview revealed that staff informed them that on 10/10/2025, R1 had been constantly crying and agitated the night before and early morning and was disturbing other residents. The staff explained that they were desperate to calm down R1 and gave two tablets of the Lorazepam to R1. The interview with staff revealed that R1 had been getting anxious late at night, and during this time, R1 kept going into the other residents’ rooms, bothering them and not letting them sleep. This incident took place the night of 10/09/2025; it started late at around 11:00 p.m. and continued till next morning of 10/10/2025 until approximately 2:00 a.m.; this is when the staff administered the two pills during separate times because the first pill did not calm R1 down. The staff stated that they had informed the Administrator of the concern with R1’s agitation and bothering the other residents. On the morning of 10/10/2025, staff had a phone conversation with R1’s responsible party and informed them that they had given R1 the Lorazepam. Furthermore, the staff stated that they, and the responsible party for R1 had a three-way telephone conversation with R1’s primary physician at approximately 10:00 a.m. on the same day, and the staff explained to the physician what had happened the previous night . The interview with the Administrator revealed that they were aware of the incident. Record review revealed that R1’s primary physician prescribed two medications (Buspirone 5mg. 2xd, and Trazodone 50mg. as needed) to address the concerns of insomnia and agitation. The medications were filled on 10/10/2025, and per the Administrator the facility received them on 10/14/205. Staff started assisting with medications on the same day the medication was delivered. Based on the information obtained through interviews and record review, the allegation that staff provided unprescribed medication to R1, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Interview exit was conducted. A copy of the report and Appeal Rights were issued.