complaint·January 9, 2026

LPA Hayes reviewed the facility’s Medication Administration Records (MAR) for March 2025 for R1. R1 was prescribed Levothyroxine SOD 0.175 MG, 1 tablet (175 MG) to be given daily at 5:00 AM. In a phone interview on 1/8/2026, with Executive Director (ED), Marianne Richardson, ED confirmed this medication was not given to the R1 on 3/11/2025, due to a medication delivery issue with Omnicare. On 1/9/2026, LPM Richardson reviewed a proof of medication delivery statement from Omnicare which indicates that Levothyroxine was shipped out on 3/10/2025 but was not delivered to the facility until 3/11/2025 at 1:47 PM. Due to the delay in delivering the medication timely to the facility, it caused R1 to not receive their dose of Levothyroxine on 3/11/2025 on time. LPA Hayes also reviewed the Medication Administration Records (MAR) for R1, dated 3/2025, and confirmed that the medication was marked as a missed medication. LPA Hayes interviewed multiple residents residing at the facility regarding their experiences with medication administration. Three of three residents who participated in the medication management program reported receiving their medications as scheduled and did not report missed, delayed, or incorrect medication administration. Community Director (DW1 ) reported that the facility uses an electronic medication administration system. They stated that medications are administered according to physician orders, that medication orders must be entered into the electronic system prior to administration, and that any gaps in medication are reported to the residents’ physician and family. Based on the review of records, interviews, and facility statements, the investigation determined that R1 did not receive Levothyroxine medication as prescribed on March 11, 2025. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED . This facility is being cited per Title 22 CCR Section 87465 (a)(4) being cited on the attached LIC 9099D. An exit interview, appeal rights and a copy of this report were left with Marianne Richardson, Executive Director.