complaint·August 15, 2025

During the visit on 7/25/25, LPA reviewed medications for ten residents. LPA observed all of R1’s medications in the med room, including the Nitroglycerin tablet, and they are managed by the staff. The Nitroglycerin medication is a PRN and is given to the resident upon request. LPA interviewed the medication staff regarding this allegation. One of the staff confirmed that the Nitroglycerin medication could not be found on 7/17/25 when R1 requested it. Staff stated another staff helped search for the medication but could not find it either, so R1 was sent out to the hospital. The staff on the next shift was able to locate the medication. Eight (8) out of ten (10) residents stated that the staff do not give them their medications on time and/or that they were missing. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided. The meal plan is created with residents’ suggestions and their dietary needs. The cooks stated they include servings from the different food groups and ensure there are alternatives each day. Staff stated they follow any special diets that each resident may have. If a resident’s dietary needs change, the kitchen staff are informed right away. Staff interviewed also stated there are sugar-free drinks and desserts available for residents. Staff provide sugar-free drinks and desserts to those who are diabetic; however, if they choose to get the regular ones, staff will give to them even though they remind them they should not consume sugary items. During the kitchen tour on 7/25/25, LPA observed sufficient food supplies with fresh vegetables and sugar-free drinks and desserts. The kitchen has a list of residents who have dietary needs/restrictions and are diabetic. Two (2) out of (10) residents interviewed feel that the facility does not have sugar-free drinks and desserts, and the food is cooked with lots of sugar. Eight of the residents stated the facility serves sugar-free items and offers a variety of food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator via telephone. A copy of this report, along with the appeal rights, was provided.