complaint·April 23, 2026

Allegation: Staff mismanaged resident's medication It is alleged that facility did not monitor R1’s medication upon transfer from the Skilled Nursing facility and discontinued R1’s insulin. On February 10, 2025, around 8:00 AM, R1 did not respond to staff’s verbal or tactile stimuli. R1 was breathing normally and unlabored. R1’s blood sugar level was at 978, blood pressure at 72/47, and a heart rate of 78, 9-1-1 was called and R1 was taken to the hospital. R1 was diagnosed with Diabetic Ketoacidosis (DKA), Severe Anemia, and Seizure. Based on the investigation, record review shows R1 was admitted to the Memory Care unit of the facility on February 4, 2024. Per Discharge Summary from Providence Skilled Nursing facility dated February 3, 2025, Lantus Solostar was noted with 4 refills with start date February 3, 2025, and without an end date. Per review of R1’s Medication Administration Record (MAR), the start date for Lantus Solostar was February 4, 2025, and discontinued date on February 5, 2025. R1 did not receive any Lantus Solostar per interviews with four out of four staff. However, there is no physician’s order for R1 to discontinue the Lantus Solostar. During the interviews, four out of four staff and four out of four witnesses corroborated with the allegation that staff mismanaged resident's medication due to lack of communication between the facility and Skilled Nursing Facility regarding R1’s discharge medications. S2 stated the facility did not administer the Lantus Solostar as it was marked as “discontinued” (DC) per Order Summary report. W4 stated that Lantus Solostar was circled to confirm that the medication needed to be continued. W3 and W4 also confirmed that on page 2 of Providence discharge summary dated February 3, 2025, lists Lantus Solostar as a continued medication. W3 stated that R1 has uncontrollable diabetes which could go extremely high or low without proper medication. All witnesses and staff confirmed that the Lantus Solostar medication was mismanaged causing R1’s hospitalization. R1 was diagnosed with Diabetic Ketoacidosis, severe anemia, and seizures. Continued on LIC9099C . Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff mismanaged resident’s medication was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An Immediate Civil Penalty is being assessed in the amount of $500. See the attached LIC421IM. A Civil Penalty is pending determination as per Health and Safety Code 1548(c)(1). An exit interview was conducted, and a copy of this report including the LIC421, LIC811, and the appeal rights were provided to Administrator Austin Morris.