complaint·December 29, 2025

THIS REPORT HAS BEEN AMENDED TO INCLUDE A SECOND DEFICIENCY ON LIC809-D PAGE. Regarding the allegation, Staff gave medication to the wrong resident , it is alleged that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol prescribed by R1’s doctor. Based on record review, R1’s MAR dated November 3, 2025, indicates 50mg of Tramadol was administered to R1 at 8am. However, the Morning Controlled Drug Administration Record (MCDAR), an internal record used by facility to count medication during shift change, has an entry for November 3, 2025, that was crossed out with the word “error”. There are no additional entries for the morning dose which indicates the resident was not administered Tramadol for the morning pass on November 3, 2025. This conflicts with the MAR mentioned above. A record review of R2’s MAR dated November 3, 2025 indicates 10-325mg of Oxycodone-Acetaminophen was administered to R2 six times throughout the day, however, the Controlled Medication Record (CMR), a record used by facility to count medication during shift change, has seven staff entries for November 3, 2025 with one crossed out and the words “error got wet” noted beside the date. During the investigation, interviews were conducted and three out of six staff confirmed that on November 3, 2025, Staff #1 (S1) administered R2’s medication of Oxycodone to R1 instead of Tramadol and R2 received the usual dose of Oxycodone as well. One staff interviewed stated the medication count for R1 had an extra dose of Tramadol, causing the count to be “off”. A second staff stated R2 was missing a dose of Oxycodone, which was causing that resident’s count to be “off”. A third staff member stated they were aware that R1 was given R2’s medication on November 3, 2025, as staff counted medication and discovered the wrong medication was given to R1 instead of R2 on that date. S4 stated they do not recall the errors occurring on that date and could not confirm or deny if a medication error did or did not happen. S4 reviewed the records and stated that a Medication Destruction Record is used by facility when any medication is damaged or disposed of but could not provide any record of disposal for R1 and R2 on November 3, 2025. Interviews were attempted with residents and LPA was unable to qualify Resident #1 due to diagnosis and Resident #2 was out of the facility at the time of the visit. Regarding the allegation, Staff did not follow reporting requirements , it is alleged that staff did not report the medication error for R1 to resident's family, physician, and the Department. Interviews were conducted and three out of six staff confirmed the allegation. One staff stated R1's family was not informed about the medication being administered incorrectly. A second staff stated R1's physician was not informed about the medication error. A third staff stated they were specifically told not to document the medication error of R2’s medication of Oxycodone being administered to R1 instead of Tramadol prescribed by R1’s doctor. A record review revealed that as of December 29, 2025, no incident reports were submitted to the Department regarding R1’s medication error. Executive Director was interviewed and denied knowledge of the medication error that occurred on November 3, 2025. Based on LPA's observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegations Staff gave medication to the wrong resident and Staff did not follow reporting requirements are deemed SUBSTANTIATED. Deficiencies are being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted with Executive Director Melanie Washington, and a copy of this report, LIC 9099-D, and appeal rights were provided at exit.