complaint·July 28, 2025

Regarding allegation: Staff administered the incorrect medication to resident. It is alleged that caregiving staff gave R1 medicine on 7/21/25 at around 8:00 p.m., which is not prescribed to R1 and was told to take it. It is alleged that when R1 told staff the medication wasn’t theirs, caregiving staff told R1 “You gotta take it.” The investigation revealed the following: Interviews with Staff 1 – Staff 6 (S1-S6) revealed, caregiving staff are not allowed to administer medication to residents at any time. S1-S6 stated, the only staff who are allowed and qualified to administer medication are medical technicians per education training, facility policy and procedures. However, interview with S3 (caregiver) indicated, they were asked by S5 to please give R2 (R1’s roommate) a medication as S5 waited outside R2’s room with medication cart during medication pass, due to R1 not allowing S5 to enter R1’s room. S3 stated, they took the cup with a “pink” pill from S5 because S5 asked S3 to please give R2 the medication, even though S3 is aware that only medical technician staff are allowed to do so, which S3 is not. S3 stated, they proceeded to enter R1/R2’s room, and once in the room, S3 placed the cup with the medication on R1’s walker table. S3 stated, the medication was meant for R2 and not for R1 which at that time, S3 was able to retrieve the cup with the medication from R1 and proceeded to give it to R2. S5, denies the allegation; however, record review of R2’s medication administration record (QuickMar) for July 2025 indicates, S5 signed off on administrating R2’s bedtime routine medication at 8:00 p.m. on 7/21/25, which S5 does admit to being the staff who passed R2’s medication on that day. Interview with R1 indicated, S3 gave them the cup of medication with a “pink” pill which they did not take due to medication not being part of their regular routine medication prescribed by their doctor. R1 further indicated, they do not take any “pink” pills with their routine medication and can identify exactly which medication R1 takes, daily. Review of R1’s medication indicated, R1 does not take any medication fitting the description of the pill given to them by S3 on 7/21/25. Further review of R2’s medication revealed, R2 takes medication which includes a pink pill of Rosuvastatin Calcium 20mg tab which was administered on 7/21/25 at 8:00 p.m. by S5. R2 was unable to be interviewed due to being hospitalized at the time of visit. LPA observation, record review, and staff and resident interviews, corroborate the allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.