Complaint·March 21, 2025

On March 20, 2025, LPA received a call from staff member (S1) indicating that a medication error was discovered on March 18, 2025, and the facility would be submitting an incident report to the Department. During today's visit, LPA reviewed an Unusual Incident Report (SIR) regarding incident that was reported on March 20, 2025. SIR received states the following information. "On 3/18/25 in the afternoon PM Medtech [staff member S2] found what appeared to be resident's morning medications in [their] apartment, not taken. After examination it was determined to be [their] morning medications. This was reported to the nurse on call and the executive director." SIR indicates that a training was completed for all medtechs on March 18, 2025 regarding proper medication passing. Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents. On March 20, 2025, LPA received a call from staff member (S1) indicating that a medication error was discovered on March 18, 2025, and the facility would be submitting an incident report to the Department. During today's visit, LPA reviewed an Unusual Incident Report (SIR) regarding incident that was reported on March 20, 2025. SIR received states the following information. "On 3/18/25 in the afternoon PM Medtech [staff member S2] found what appeared to be resident's morning medications in [their] apartment, not taken. After examination it was determined to be [their] morning medications. This was reported to the nurse on call and the executive director." Based on records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.