complaint·July 10, 2025

LPA interviews with three out of four staff stated R1 did not receive one medication dosage on the evening of March 2, 2025 because R1 was sleeping. The remaining one out of four staff was unsure. In addition, two out of four staff stated R1 did not receive one medication dosage on May 14, 2024 because R1 was sleeping. The remaining two out four staff were unsure. LPA records review of R1’s medication record confirm R1 did not receive one medication dosage in the evening of March 2, 2025 and May 14, 2024. In addition, LPA records review of R1’s medication record from October 2023 through June 2025 showed multiple instances of various medications not marked as being administered. Three out four staff stated that there are times when staff will forget to mark medications as administered in their medication tracking system. LPA reviewed in-service training completed on May 20, 2025 focused on medication documentation for staff involved in administrating medications. LPA observed R1’s medications in the medication room. Regarding the allegation staff did not keep resident's authorized person informed about the resident's care, it was reported the facility never told the responsible person (RP) when medication was not provided to R1. LPA interviews with three out of four staff stated RP was informed verbally on March 3, 2025 when R1 missed one medication dosage on March 2, 2025 during a visit by RP. The remaining one out of four staff was unsure. One out of four staff stated RP was not informed when R1 missed one medication dosage on May 14, 2024. The remaining three out of four staff were unsure. LPA review of R1’s medication record documented refusals and in some cases, documented RP’s presence during R1’s medication refusals. Three out of four staff stated responsible parties are usually informed about a resident’s refusal of medications. The remaining one out of four staff stated they do not notify anyone unless it’s a recurring issue. The facility did not provide any documented evidence of informing RP about R1’s refusal of medications. Based on LPA interviews and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.