complaint·September 23, 2025

In regard to the allegation” Staff did not dispense medications as prescribed”, It is alleged that staff administered wrong medication to R1 resulting in a positive urine test of an opioid causing R1 to be hospitalized. During interview with Administrator, and staff three (3) out of five (5) stated that to their knowledge no medication error has occurred. Two staff stated that they do not give out medication. During interviews it was revealed that R1 took Morning medication at 8:00 AM given by med-tech and that by 9:20 AM R1 appeared weak and was slurring. S3 stated that in the early morning R1 was awake and given breakfast with no problems. S4 stated the night before R1 was taken to hospital there were no signs of any problems during his/her shift. LPA attempted to interview six (6) residents but due to their cognitive condition LPA was unable to interview them. LPA interviewed R1’s family and it was revealed that R1 only takes two medications omeprazole in the morning, and Zoloft (sertraline) which him/her dispenses in the afternoon and when tested at hospital Tricyclic was found in urine. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Administrator.