complaint·February 11, 2026

On January 22, 2026, LPA conducted a medication count for residents R1, R2, R3, and R4, comparing each resident’s Centrally Stored Medication Form (CSMF) and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed one (1) medication for R2 that had one (1) tab over the amount documented. R2's MAR did not indicate any refusals or missed passes of medication. LPA observed one (1) medication for R4 that did not have a documented start date, but appeared to be administered for five (5) days. LPA observed that another bottle of the same medication indicated a start date of five (5) days prior stored in the resident's overflow medications. Count of the ladder bottle was below the amount documented on R4's CSMF. LPA observed two (2) other medications that were over the amount documented on R4's CSMF. LPA observed an influx of bottles located in R4's overflow medications which could have been used over the course of R4's admission, but R4's documentation did not reflect the use of these bottles. Interviews conducted with R2 and R3's authorized representatives indicated that they did not have any concerns regarding medication administration at the facility. Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.