complaint·April 23, 2025

The facility staff failed to observe R1’s change of condition when they were in R1’s bedroom completing the resident check between 8:30 AM and 8:45 AM. Based on the evidence discovered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because of the preponderance of evidence the standard has been met. During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Administrator Lisa Hunt, along with a copy of the appeal rights. On 6/28/2023, S2 administered R1’s medication incorrectly. R1’s medication was supposed to be lowered to half of the normal dosage, but instead S2 increased R1’s dosage three (3) times the prescribed amount. Thirty-six (36) hours later R1 suffered a stroke and was transported to receive medical care. Based upon investigation, medication documentation did not substantiate that R1 stroke was due to the inaccurate medication dosage. The allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Lisa Hunt.