complaint·October 9, 2025

LPA Moleski interviewed five facility staff members regarding R1's care (S1-S5). In interviews, multiple staff members said that R1 sometimes refused care (S1, S2, S3, S4, S5), and that R1 did not always use their call button when they needed assistance (S1, S3). R1's care plan as of June 2025 indicated that R1 was to receive assistance with two showers weekly and total assistance with toileting. However, residents retain the right to refuse any service per 22 CCR Section 87468.1(a)(16). LPA Moleski reviewed R1's MARs dated between December 2024 and June 2025. LPA Moleski did not observe consistent missed doses or other indicators of systematic mismanagement of R1's medications. In an interview, R1 said they get their medications every day and did not express concerns with missing doses of their medications. In interviews, two medication technicians (S2, S5) said that there were instances wherein R1's painkillers could not be delivered immediately due to delays in getting their orders refilled. S2 and S5 said that, because the painkiller is a controlled substance, staff were not able to order the medication well in advance, and sometimes the order was delayed before being delivered to R1's pharmacy. LPA Moleski reviewed all progress notes taken during R1's residency at this facility and observed that staff documented their attempts to get orders filled in a timely manner when this occurred. The department has determined the following as it relates to the allegations that the facility is charging resident for services not being provided and that staff do not ensure residents medications are properly managed: Based on interviews, record review, and observation, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Ocegueda. S1 pointed out that R1's electronic MARs differ from R1's paper MARs. R1's eMARs show that R1 did not receive any such medication on 4/27/25. However, R1's eMARs do include timestamps showing when medication is passed. These timestamps show that R1 did on occasion receive two half tablets within one 24-hour period during the months of April and May 2025. For example, on April 8, R1 received a half tablet at 10:17 p.m., and received another half tablet on April 9 at 8:46 p.m. On Aril 25, R1 received a half tablet at 9:50 p.m. and received another half tablet on April 26 at 8:13 p.m. On May 3, R1 received a half tablet at 9:37 p.m. and on May 4 received another half tablet at 9:07 p.m. According to R1's eMARs, R1 received their last dose of the painkiller as a once daily PRN on May 11, then began taking the medication again as a twice daily routine medication on the evening on May 13. However, R1's change orders were dated May 9. According to R1's paper narcotic MARs, R1 continued to receive one half tablet each day on May 9-13. The first day R1 received two daily doses of this medication was May 14th, according to both R1's paper MARs and their eMARs. LPA Moleski observed that R1, in January 2025, had a PRN order on file to take one tablet of the same painkiller twice daily. LPA Moleski observed that R1 received only one tablet for most days the medication was provided during that month. Only on one day, January 5, R1 received two tablets. In an interview R1 said that facility medication technicians told R1 they could only take one tablet, despite being able to take two tablets per day as needed, per their prescription order. LPA Moleski observed a staff member count out R1's painkiller on 6/4/25 and compared the number of pills missing from the bottle with the doses administered per R1's paper narcotic MARs. The count indicated that the number of doses recorded on the paper MARs was accurate as of that date. The department has determined the following as it relates to the allegation that staff do not ensure medications are dispensed as prescribed: Based on record review and interview, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Ocegueda. Appeal rights and a copy of this report were left with Ocegueda.