Complaint·October 14, 2025

Continued from LIC9099... During this visit, an interview with Staff 3 (S3) further revealed that S1 made the medication error. On 08/27/2025, LPA received another incident report for another medication error made by S1 with Resident 2 (R2). No harm to resident was reported. An interview conducted today with Staff 2 (S2) revealed that as a result of these two medication errors, S1 has been terminated as reflected on Performance Improvement Action Plan/Termination Letter dated 08/26/2025 . Based on observations made, interviews conducted and records obtained, the allegation that staff does not ensure medications are dispensed as prescribed to residents is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.