complaint·February 6, 2026

acknowledged receipt of this order. However, the Physician’s Report dated December 16, 2025, indicated that R1 was unable to manage their own medications, with a side notation stating “certain medications.” ED Galicia and HWD Mata explained that R1’s primary physician later submitted an updated Physician’s Report dated February 3, 2026, revising the assessment to reflect that R1 is able to administer and manage their medications independently. ED Galicia reported that the facility awaited clear clarification regarding medication management responsibilities due to the conflicting documentation. Additionally, R1 had expressed a preference to self-administer one medication while having the facility manage the remainder; however, the physician ultimately ordered that R1 could self-administer all medications. As of February 5, 2026, with the updated Physician’s Report and physician’s order on file, R1 has been self-administering medications. LPA interviewed five staff members; all five stated that they follow physician orders and cannot administer medications without written authorization or clarification. Staff reported that all medication administration requires documented physician direction. LPA also interviewed four residents regarding medication management. Three residents stated that the facility follows physician orders. One resident reported waiting for clarification on their own orders but acknowledged understanding the need for physician authorization and clarification. It was alleged that staff mismanaged resident’s medications The investigation determined the following: Five out of five staff interviewed stated that the facility does not mismanage medications. Staff explained that medications are administered within an accepted one-hour grace period before or after the scheduled time, consistent with standard practice, and that residents are informed of this administration window. Staff reported that delays may occasionally occur due to the volume of residents requiring medication assistance; however, they stated that doses are not skipped or missed and that all administration is documented on the Medication Administration Record (MAR). Staff also indicated that residents sometimes refuse medications, which is documented accordingly. (Complaint Investigation continued on LIC9099C) ED Galicia reported an instance in which R1’s medications on hand did not match the physician’s order; therefore, staff could not administer the medication until the discrepancy was resolved. MAR documentation reflected occasions when R1 was not present in the community or declined to wake at the scheduled administration time. LPA interviewed four residents. One resident stated there was no medication mismanagement. Other residents expressed concerns about medications not being given exactly on the scheduled time or about last-minute reordering; however, they acknowledged staff workload and confirmed medications were generally received within the one-hour grace period. One resident emphasized the importance of timely medication due to medical conditions but did not report missed doses. It was alleged that staff did not administer resident medication as prescribed. The investigation determined the following: All five staff interviewed stated that medications are administered exactly as prescribed, following physician orders regarding dosage, timing, and instructions. One staff member specifically noted that residents receive the precise dosage ordered. LPA interviewed four residents, all of whom reported that staff administer medications as prescribed. Residents stated that dosages are provided correctly and generally within the appropriate timeframes. Examples included morning medications being administered in the morning and the correct number of pills being provided per physician direction. Some residents expressed concern about the proximity of certain dosage times and felt the facility should continue monitoring scheduling closely; however, no resident reported receiving incorrect dosages or medications inconsistent with physician orders. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Carmen Galicia. A copy of the report was provided to the facility.