Complaint·April 29, 2026

LPA observed one (1) medication for R2 to be over the documented amount and one (1) medication to be under the documented amount. R3 had three (3) medications that were under the documented amount. On March 19, 2026, the department received an Unusual Incident/Injury Report LIC624 indicating that on March 4, 2026 the facility was notified that R1's medications were not being given as prescribed. The facility had nurses from an outside vendor conduct audits on all medications, which was concluded on March 18, 2026. The investigation/audit found that R1 was being given an incorrect dosage of medications. The facility indicated that they notified R1's primary care physician. The audit also found that start dates were not being consistently documented for several residents, some medications were expired, and some medications were not being stored as ordered. Due to investigation/audit findings, the facility initiated a staff training for all Med Techs covering the job description, medication assistance procedures, and medication basics. The Acting ED indicated that all Med Techs were shadowed on the medication carts as well. The facility provided LPA with the sign off sheets for all staff that participated in the training as well as their final exams following the training. The facility took corrective action against staff involved in mismanaging residents' medications. The facility also terminated one staff after making an error following the retraining. Based on a medication count, records reviewed and interview conducted, 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 conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.