complaint·March 24, 2026

The Department conducted interviews with five (5) staff members, all of whom denied over-medicating R1. All staff members interviewed stated that medication technicians are required to document and sign off after every medication was administered to residents in care, in accordance with physicians’ prescriptions. The Department’s review of medication administration records corroborated the staff members’ statements. The Department obtained and reviewed R1’s medical records. R1’s medical records did not have any diagnosis or assessment of overmedication. The Department attempted to interview R1, but R1 was unable to answer any questions due to their cognitive condition. Based on interviews conducted and records review, the Department’s investigation did not provide enough information to corroborate the allegation. Therefore, the allegation that facility staff overmedicated resident resulting in hospitalization is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. However, R1 resided at an assisted living side of the facility, and R1’s care plan did not include any intervention strategies as it only showed “reminders only” for ambulation and fall risk areas. The Department conducted an interview with resident service director who stated that frequent room checks were done, but R1’s care plan reflected the standard two-hour room checks. The Department conducted a review of R1’s hospice records which required R1’s hospital bed to be set at the lowest position due to R1’s fall risk. R1 was placed under hospice care starting from April 2024. The Department conducted a tour of the facility and observed that R1’s room contained both a regular queen-size bed and a hospital bed. The Department’s interviews with resident care coordinator and Staff #1 (S1) revealed that R1 had used the regular bed provided by R1’s family, rather than the hospital bed provided by R1’s hospice agency. The former resident service director asked R1’s family to remove the regular bed, but the regular bed was not removed. The Department conducted interviews with five (5) staff members, all of whom stated that R1 wandered a lot and required frequent redirection as R1 was confused most of the time. Two (2) out of five (5) staff members interviewed stated that they were not aware of R1’s high fall risk status. Based on the Department’s record review and interviews conducted, the Department determined that R1 required higher level of care than the facility had provided. The Department’s investigation provided enough information to corroborate the allegation that facility staff did not adequately address resident’s fall risk resulting in injuries. This allegation is substantiated . An immediate civil penalty of $500 is being assessed. In accordance with CCR Code Section 87468.2(a)(4), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided, along with LIC9099D, LIC421IM and Appeal Rights.