complaint·October 9, 2025

LPA Moleski reviewed R1's MARs. LPA Moleski observed that R1 had been taking the medications four times daily between September 13 and 17. R1 received one dose on the morning of September 18, at which point the medication was marked discontinued in R1's MARs. The medication was started again at 3 p.m. on September 25, and R1 continued to receive their medications as prescribed for the rest of the month. LPA Moleski reviewed a fax sent to R1's prescriber dated 9/29/25 reporting the error. The fax stated that R1 received an order to increase a different order for the same medication on 9/18/25. "However, the order was not transcribed correctly," the fax read." As a result, the existing order ... was inadvertently discontinued. This led to [the medication] being missed from 9/18/2025 at 10:00 a.m. until 9/25/2025 at 12:00 p.m." In an interview, S2 admitted to incorrectly transcribing the order. LPA Moleski reviewed fax and email records and observed that no incident report was received by the Community Care Licensing Division (CCLD) regarding this error. S2 said no report was sent to CCLD. 22 CCR Section 87211(a)(1)(D) requires that licensees report " any incident which threatens the welfare, safety or health of any resident... " This reporting error will be addressed in a separate case management report. The department has determined the following as it relates to the allegation that staff are not administering medication(s) to a resident in care as prescribed: Based on interviews and record review, 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 Revera. Appeal rights and a copy of this report were left with Revera.