complaint·August 14, 2025

LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated October 22, 2024 for an incident that occurred on October 21, 2024 regarding a medication error. SIR states that, on October 21, 2024, while conducting a weekly self Audit of the Assisted Living Med-Room, it was discovered by Health Services Director (HSD) that an order of Prednisone was being given to R4 incorrectly. Facility reported that the medication order was placed in the facility’s medication administration record from the pharmacy and an additional order on paper was placed in the system by a previous Director. One order stated morning dosage, and the second order stated evening dosage, creating confusion and wrong dosages given from September 22, 2024 to October 18, 2024. Upon discovery, the order was corrected and given as prescribed following correction. SIR states that facility would continue doing weekly audits of the Med-Room, HSD would be approving all orders, and an in-service training would be completed with Med-Techs. On June 3, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the residents. LPA observed two (2) of five (5) medications for R1 were over the amount documented by two (2) tabs. After missed passes were factored into count, R1's MAR did not include any additional information to justify the two (2) medications over by two (2) tabs. LPA observed four (4) of five (5) medications for R2 to be off-count in relation to the amount documented. One (1) medication for R2 should have been finished and still had four (4) tabs available, one (1) medication was over by one (1) tab, one (1) medication was over by four (4) tabs, and one (1) medication was under by 20 tabs. R2's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented. LPA observed three (3) of seven (7) medications for R3 to be off-count in relation to the amount documented. One (1) medication for R3 should have been finished and still had nine (9) tabs available, one (1) medication was over by two (2) tabs, and one (1) medication was over by three (3) tabs. R3's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented. Based on 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 was provided. Signature on these forms acknowledges receipt of these documents. Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed a resident in need of care and not receiving assistance from facility care staff. Interviews with residents R3, R5, R6, R7, and R8 indicated that they are treated well by facility staff and that their care needs are being met. Interviews with residents did not indicate any concerns regarding care staff providing assistance with ADLs. Interviews with residents indicated that they did not witness any residents in need of care and not receiving assistance from facility care staff. Interview with R3's authorized representative indicated that they have no concerns regarding care being provided to R3 and they felt caregivers do a good job providing care at the care home. During visits conducted on June 3, 2025, July 30, 2025, August 7, 2025, August 13, 2025, and August 14, 2025, LPA did not observe any residents in need of care and not receiving assistance from facility care staff. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Relevant party reported to the Department that resident (R3) was observed to be residing in the Assisted Living Unit (ALU) of the facility while participating in activities and spending most daytime hours in the Memory Care Unit (MCU) of the facility. A review of Title 22 regulations did not indicate any violations distinguishing care needs of residents in ALU settings in opposition to care needs of residents in MCU settings. Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed the facility retaining residents beyond a level of care they can provide, including prohibited health conditions. Interviews with residents R7 and R8 indicated that they have never witnessed residents residing at the facility who are in need of a level of care the facility cannot provide. LPA reviewed records for R3, including R3's Physician's Report (LIC 602A) dated July 10, 2024 and Resident Assessments dated October 13, 2023, April 3, 2024, July 12, 2024, December 12, 2024, January 1, 2025, and June 19, 2025, which did not indicate that R3 sustained any prohibited health conditions or required a level of care that the facility could not provide. Interview with R3's representative indicated that they had no concerns regarding the care provided at the facility and they feel care staff do a good job providing care to R3. Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.