complaint·August 25, 2025

A comprehensive review of facility records was conducted and uncovered inconsistencies in the scheduling of Medical Technicians (MedTechs) on the staff calendar. LPA identified 16 instances where MedTech coverage appeared to be missing for at least one shift, prompting concerns regarding the administration of medications. The investigation confirmed that a qualified MedTech was present during 14 of the 16 shifts in question, thereby negate there was inappropriate coverage. Information obtained from an interview with S2, it was determined that abrupt changes were made to the schedule and the staff schedule was not updated. On February 1, 2025, no MedTech was assigned during the Night Operations Shift (NOC), resulting in an estimated two residents not receiving their scheduled medications and any PRN requests by the residents in care. Additionally, on Saturday April 26, 2025, an unexpected staff call-out before the PM shift left the facility without MedTech coverage, leading to a failure in dispensing scheduled medications to the facility residents in care. Interviews with ED and staff members confirmed that efforts were made to secure coverage; however, due to emergencies, pre-existing schedules, and the short notice, a qualified replacement could not be arranged on that Saturday shift. Based on interviews and record reviews, the allegation that staff did not administer prescribed medications to residents in care is Substantiated. 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 to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.