complaint·June 29, 2025

Allegation: Staff do not administer residents’ medication as prescribed The allegation alleges that staff S2 are providing residents with their medication late or not at all. During the facility tour, LPA conducted a medication review for ten (10) residents. LPA reviewed medication orders, eMAR, and the resident’s medication. LPA observed ten (10) out of ten (10) resident’s medications are consistent with properly documented records. During file review, LPA received and reviewed ten (10) resident Med Summary for the month of June for the C Wing and observed S2 provided R16 their 06/15/2025 5PM medications at 7:08PM, on 06/22/2025 5PM medications were provided at 6:43PM, on 06/23/2025 5PM medications were provided at 8:10PM, and on 06/24/2025 5PM medications were provided at 11:16PM. No notes were in the system as to why the medication was provided late. Staff S2 provided Resident R17 their 06/02/2025 8PM medications were provided at 9:39PM, 06/04/2025 8PM medications were provided at 9:58PM, on 06/08/2025 8PM medications were provided at 9:11PM, 06/09/2025 8PM medications were provided at 9:15PM, on 06/10/2025 8PM medications were provided at 9:06PM, and on 06/11/2025 8PM medications were provided at 9:34PM. LPA did not observe any notes about why the medication was provided late. S2 provided R18 their 06/25/2025 7PM medication was provided at 8:21PM, with no notes indicating why medications were provided late. S2 provided R18 their 06/02/2025 4PM medications were provided at 5:17PM, 06/11/2025 5PM medication was provided at 6:57PM, 06/12/2025 5PM medications at 7:04PM, and on 06/18/2025 5PM medications were provided at 9:25PM. No notes were observed indicating why the medications were provided late. S2 provided R19 their 06/01/2025 8PM medications were provided at 9:12PM, 06/02/2025 8PM medications were provided at 9:14PM, 06/16/2025 8PM medications were provided at 9:11PM, 06/21/2025 6PM medications were provided at 7:49PM, 06/22/2025 8PM medications were provided at 9:15PM, 06/24/2025 8PM medications were provided at 9:46PM, and 06/27/2025 6PM medication was provided at 7:31PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R20 their 06/02/2025 5PM medications were provided at 6:23PM and on 06/04/2025 5PM medications were provided at 7:58PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R21 their 06/01/2025 7PM medications were provided at 8:24PM, 06/05/2025 7PM medications were provided at 8:16PM, 06/06/2025, 5PM medications were provided at 7:55PM, 06/13/2025 5PM medications were provided at 7:31PM, 06/15/2026 7PM medications were provided at 8:11PM, 06/18/2025 7PM medications were provided at 8:27PM, and 06/21/2025 7PM medication was provided at 8:24PM. LPA did not observe any notes indicating why the medications were provided late. S2 provided R5 their 06/04/2025 6PM medications were provided at 9:23PM, 06/07/2024 4PM medications were provided at 7:13PM, 06/14/2025 4PM medications were provided at 6:44PM, and 06/17/2025 6PM medication was provided at 7:10PM. LPA did not observe any notes indicating why medications were provided late. LPA observed seven (7) out of ten (10) residents were provided with their medications either late or early. Additionally, LPA receuved and reviewed Employee Corrective Action Form Written Warning for a former Med Tech who on 05/14/2023, provided a resident with their afternoon medication and did not document it properly resulting in the resident receiving the medication twice. LPA received and reviewed an Employee Corrective Action Termination for a former Med Tech for an incident that occurred on 01/10/2024, where the Med Tech left at the end of their shift not informing management that the oncoming shift had not arrived, and 19 residents did not receive their medications. During interviews with Staff S4-14, were asked if residents are provided with medication as prescribed, six (6) out of ten (10) stated residents are provided medications as prescribed. Additionally, four (4) out of ten (10) stated they have reported S2 for not providing medications on time or as prescribed and nothing has been done. During interviews with Residents R5-R14, were asked if they receive their medications as prescribed, four (4) out of ten (10), stated they receive their medications as prescribed and six (6) do not receive assistance. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Business Office Director, Teresa Ramirez , and a copy of this report and the appeals rights was provided. Allegation: Staff dispense medications to residents without a prescription The allegation alleges that staff dispense medications to residents that there is not a prescription for. During the facility tour, LPA conducted a medication review that consisted of reviewing resident medication orders, the eMAR, and residents centrally stored medications for ten (10) residents. LPA observed ten (10) out of ten (10) centrally stored medications have a prescription order from the physician. During interviews with Staff S4-S14, were asked if residents are provided medications without a prescription, ten (10) out of ten (10) stated residents are not provided medications without a prescription. During interviews with residents R5-R14, were asked if they received medications that are not prescribed to them, four (4) out of ten (10) stated they are not given medication that are not prescribed to them, and six (6) of the residents do not receive medication assistance. Allegation: Resident wandered away from the facility due to lack of supervision The allegation alleges that a resident wandered away from the facility due to lack of supervision from staff. During the facility tour, LPA observed staff in common areas interacting with residents. LPA observed staff providing escort service to residents, ensuring residents make it to their destination safely. LPA observed staff in the common areas in the Memory Care Unit providing supervision and activities. During file review, LPA received and reviewed an incident report dated 08/21/2024 for R15, who was observed by staff, exiting out of a perimeter door. Staff asked R15 where they were going and R15 responded they were looking for their spouse. LPA reviewed R15’s Physician’s Report dated 07/26/2023, that indicates R15 has a diagnosis of Dementia and has a behavior of wandering and is at risk if allowed to leave the community unsupervised. LPA received and reviewed the Charting Notes for R15 that indicates R2 was moved from the assisted living unit to the memory care unit on 02/26/2024. Prior to moving into the memory care unit R2 was living in the assisted living unit with their spouse. During interviews with Staff S4-S14, were asked if they feel there is adequate staff to supervise residents, ten (10) out of ten (10) stated yes there is enough staff to provide supervision for residents. Staff S8-S12 stated residents who have spouses in other parts of the facility are either taken to that part of the facility to be with their spouse or their spouse is brought to them. Additionally, Staff S4-S14 were asked if there have been any incidents of elopement in the past year, four (4) out of ten (10) stated there has been an incident of elopement from the memory care unit where a resident exited and staff followed them to the parking lot. During interviews with Residents R5-R14, were asked if there is adequate staff to supervise residents, ten (10) out of ten (10), stated yes they believe there is enough staff to supervise residents. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Business Office Director, Teresa Ramirez, and a copy of this report was provided.