Complaint·May 1, 2026

Allegation: Staff gave a resident the wrong medication. It is alleged that facility staff gave a resident in care medication for two days that were prescribed to a different resident in care. On 04/09/26 from 11:00 am- 12pm LPA conducted Interviews with S1-S4 regarding the allegation above. 4 of the 4 staff interviewed denied the above allegation. Per 4 of 4 of the staff interviewed, residents with the same or similar name staff are verifying birth dates prior to administering medications. Additionally, 2 of the 4 staff interviewed reported that the facilities electrical medication administration record (EMAR) has some of the resident’s pictures which are also used to confirm that the medication is being administered to the correct resident. On 04/09/26, 4 of the 4 staff interviewed reported that a supervisor is notified if a medication error occurs. On 04/09/26 from 1pm- 2:30pm LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above. 1 of the 10 residents interviewed reported managing their own medications therefore they have no knowledge of the allegation above. 2 of the 9 residents interviewed confirmed the allegation above and report they made the staff aware of the error. On 04/22/26 LPA Villegas conducted a review of documents obtained, per preplacement appraisal dated: 07/20/21, Physicians report dated:12/09/25, and Service plan dated: 09/12/25 R1 requires assistance with medication and R1 cannot store nor administer their own medications. On 04/22/26 The Department addressed similar complaint allegation which was found to be unsubstantiated. 05/01/26 LPA Villegas conducted a medication review and observed all medications to be accounted for and documented on EMAR. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was not provided.