complaint·April 15, 2026

S1 reported that R1's responsible party arrived at the facility shortly after the call and took R1 to urgent care. S1 reported that normally they would wait for the physician or nurse practitioner to respond with a prescription or over the counter (OTC) medication to administer to the resident but R1's responsible party decided to take R1 to urgent care and when they returned they had prescriptions and medications for R1 to treat R1. The Wellness Director reported they were notified about the issue and spoke to R1's responsible party who informed them all the facility had to do was administer the medication. The Wellness Director reported that the prescriptions and medication prescribed for R1 were all verified so they administered the medication. The facility followed their procedure for the incident and contacted R1's PCP and were waiting for a response from R1's PCP on how to proceed. S1 and the Wellness Director reported it was not an emergency that required hospitalization or emergency services so an ambulance and/or 911 were not called. R1's responsible party verified that they took R1 to urgent care right after receiving the call from the facility. A review of R1's progress notes shows R1 saw their nurse practitioner on April 1, 2025, at the facility and R1 was observed to have swollen feet and a swollen toe. Medications and blood tests were ordered for R1 after the visit. On April 3, 2025 the blood draw was completed and on April 4, 2025 the new medications arrived and administered to R1. There was no mention of any swelling for R1 mentioned prior to April 1, 2025. On April 22, 2025 R1 was observed to have constipation. S1 and the Wellness Director informed R1's PCP and responsible party. S1 and the Wellness Director reported that the responsible party requested they give R1 prune juice. S1 reported they complied with the request. S1 reported that the issue wasn't an emergency and R1 did not report they were in pain so they waited for R1's PCP to respond to the report. The Wellness Director reported that R1's responsible party came to the facility to visit R1. The Wellness Director reported that the responsible party told them that R1 had a bowel movement and they were fine so they were taking R1 back home. The Wellness Director reported that R1 never returned to the facility and they never heard from R1 or they responsible party again. In each instance R1 received the proper medical care required and the facility responded in the proper manner and sought non-emergency medical care. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff ordered medications for resident in care without proper authorization, revealed the following. It was reported that the Wellness Director ordered medications for R1 and had the orders filled without proper authorization on January 6, 2025. The Wellness Director denied the allegation and reported that they met with R1's responsible party on January 6, 2025 and informed them R1 was displaying exit seeking behavior and was having a hard time adjusting to their new environment and suggested visiting R1 and having some more items from home in their room. 2 out of 2 med-techs interviewed and the Wellness Director reported that they only follow doctor's orders and don't recommend medications and suggest responsible parties should contact the physician if they have questions or concerns about medications. A review of records shows R1 moved in (December 31, 2024) with 8 prescribed medications and after seeing their nurse practitioner after move in, they were prescribed 1 additional medication with an order date of January 12, 2025. R1's was prescribed 17 different medications at the time move out. A review of records shows all medications were prescribed by a physician or nurse practitioner. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not report resident's incidents to appropriate parties, revealed the following. It was reported that R1's responsible party was not properly notified about incidents concerning R1 and that the facility didn't report the incidents to Community Care Licensing (CCL). The first incident was in January 2025 and R1 had diarrhea for multiple days, the second incident R1 had a swollen toe and feet on April 1, 2025 and the third incident on April 22, 2025, R1 had constipation. R1's responsible party verified they were notified about each incident. The Wellness Director and Staff 1 (S1) reported that none of the incidents were an emergency and R1 reported no pain. The Wellness Director and S1 reported that no of the incidents threatened R1's health, safety or well being. A review of records shows each incident was resolved and the first 2 incidents medication was ordered and administered within days of the report with no reported issues. Based on a review of facility records and California Code of Regulations, Title 22, (CCR) 87211 reporting requirements, none of the reported incidents rose to the level of submitting an incident report because all of the incidents were minor and the welfare, safety or health of R1 was not threatened. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.