Complaint·April 22, 2026

During the course of the investigation, LPA obtained a copy of R1’s physician order dated January 12, 2026, which states, “continue with blood pressure monitoring for the next two weeks.” LPA also obtained a copy of R1’s vital signs readings from January 12, 2026 to January 20, 2026 and observed R1’s blood pressure was only taken on two days, January 19, 2026 and January 20, 2026. During their interview, R1 corroborated the allegation and stated their blood pressure had not been taken during that time frame. Regarding the allegation, Staff falsified resident records, the following was revealed: It was alleged staff falsely documented R1’s blood pressure readings. During their interview, W1 stated R1’s doctor requested their blood pressure be taken daily for one week due to critically low readings. Per W1, R1’s blood pressure was only taken once between December 27, 2025 and December 31, 2025, however, the report they received on January 2nd, 2026 contained five readings, of which four were falsely presented as if they had been measured. LPA obtained a copy of blood pressure readings in question and observed Staff 3 (S3) had taken R1’s blood pressure on December 27, 2025, December 28, 2025, and December 29, 2025 and Staff 1 (S1) had taken R1’s blood pressure on December 30, 2025 and December 31, 2025. During their interview, S1 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. S1 denied taking R1’s blood pressure during that time frame due to having been on vacation at the time. During their interview, S3 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. Per S3, they did take R1’s blood pressure on December 27, 2025, however, denied having taken R1’s blood pressure on December 28, 2025 or December 29, 2025 as that was their day off. During their interview, R1 also corroborated the allegation and stated their blood pressure had only taken once by S3 on December 27, 2025. Based on R1’s record review and Staffs’ and R1’s interview, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility. LPA obtained email records between W1 and the former Executive Director, Staff 2 (S2) and on an email dated February 2, 2026, S2 states they asked S1 if they had offered the pill cutter to R1, which S1 admitted, however, there is no indication the medication in question was in fact cut or managed by S1. During their interview, W1 stated that S1 had entered R1’s room with a doctor’s letter indicating R1’s blood pressure medication dose had been decreased and asked R1 to cut their blood pressure medication in half. Per W1, they received a call at the time of the incident and were able to intervene and prevent staff from managing or cutting R1’s medication as R1 already had the decreased dose of the medication and there was no need to cut it half. The Department has investigated the complaint alleging Staff mismanaged resident's medication. After a review of R1’s records and interviews conducted with staff and witnesses, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.