complaint·October 20, 2025

The investigation revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that R1 was out of a routine medication in the month of May 2025 as facility failed to confirm if the medication was discontinued by the doctor. LPA reviewed R1’s MAR for the months of April-May 2025 and observed that on 5/18/25 R1 was not administered 1 of their routine medications with notes stating that a refill was ordered 5/19/25. LPA conducted interviews with 4 staff and 3 of the 4 staff confirmed that there was a glitch in the MAR that is used through the pharmacy where it documented the medication as discontinued and resident did not receive their medication but could not confirm for how many days R1 was without the medication. Per the MAR it appears that R1 was without medication for one day (5/18/25) as the MAR was not signed by staff and notes on MAR indicate that on 5/19/25 the medication was refilled. Additionally, LPA reviewed 15 residents medications during todays visit with no errors observed. Interviews were conducted with 11 residents and 10 out of the 11 residents denied the allegation. Based on LPAs observations, interviews which were conducted and medication review, 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. Exit interview held, and a copy of this report and appeal rights were provided.