complaint·March 10, 2025

It was alleged that a resident was prescribed a medication to be taken every day for 21 days, but was only given the medication for three days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating the allegation. LPA inspected the medications for these 10 residents and noted no medication errors. However, LPA reviewed the Medication Administration Records for these 10 residents and noted that all 10 residents have missed doses of medications in the last three months due to the medications not being in stock at the facility, including medications for blood pressure and heart conditions. Per AD, reasons for these medications not being in stock at the facility include residents’ families not bringing in the medications and doctors not timely providing refill prescriptions before the medications ran out. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that a resident sustained an injury at the facility, received stitches and needed their bandages changed daily, but the bandages were not changed for over three or four days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating any unsafe conditions, lack of medical treatment, or issues regarding care and supervision. LPA reviewed recent wound care records which showed that the most recent wound at the facility was properly treated and had healed. Interviews with AD and staff revealed that the facility is properly identifying residents with wounds, ensuring they receive proper wound care, and ensuring wound care is properly documented. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.