complaint·August 5, 2025

Allegation: Staff mishandled a resident's medication while in care The department conducted a medication audit of six (6) resident’s medications. The results are as follows: Resident #1 (R1) was prescribed Ascorbic acid and Zinc Sulfate which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma who indicated it may need to be reordered. Resident #2 (R2) was prescribed ChlordiazePOXIDE, nitrofurantoin, and thiamine which were not present in the facility. Additionally, based on the facility Medication Administration Record (MAR) for R2, facility staff administered R2 Naltrexone 50MG however there were no orders for the Naltrexone on R2’s recent medication list. Resident #3 (R3) was prescribed Ascorbic Acid, Lidocaine, Melatonin, Multivitamins & minerals, NovoLOG FlexPen and Zinc Oxide, which were not present in the facility. LPA interviewed the Administrator, Adi Lina Tuiloma and asked where R3’s medications were. The Administrator stated they were unsure. Resident #4 (R4) was prescribed Acetaminophen-rectal suppository and Morphine Sulfate, both of which were not present in the facility. Resident #5 (R5) was prescribed Cephalexin 500mg, clobetasol 0.05%, ergocalciferol 1,250 mcg, FeroSul 325mg, mupirocin 2%, nystatin 100,00 unit/gram ointment, nystatin 100,000 unit/gram powder, risperidone 0.5 mg, sennosides-docusate sodium 8.6, thiamine 100 mg, vitamin D3- vitamin K2 (MK4) which were not present in the facility. Additionally, Hibiclens 4% Liquid was with R5s medications but not list on R5s medication list. LPA reviewed facility Medication Administration Record (MAR) and did not observe the medication as being given to R5. LPA asked Staff who stated it came with R5 from the skilled nursing facility. The facility has not used the Hibiclens 4% Liquid on R5. Resident #6 (R6) was prescribed Fluoxetine 40mg which was not present in the facility. Based on LPAs medication audit and interviews, the facility did not ensure that staff did not give residents their medication as prescribed. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D As a result of today's visit deficiencies are cited. Exit interview conducted a copy of the report and appeal rights were left at the facility.