complaint·September 25, 2025

dates of 06/02/2025 and 08/02/2025 were missing without explanation or reasons at that time. Based on a review of the eMAR system utilized by this facility at this time, the section where notes and information would be entered if the medications were missed, refused, or not given did not have any information entered at this time. Based on interviews conducted during the course of this investigation, it was learned that if a date where the required initial and notes were not present in the eMar system then it would be considered that the medication was not properly dispensed to the resident at that time and missed for that time frame. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview Based on a review of the facility policies and procedures for facility personnel for all ranges of assigned tasks. duties, and classifications, it was observed that each classification came with it's own unique set of skills and requirements. It was observed that these classifications ranged from the following: Wait Staff Care Staff Medication Technicians Housekeepers Kitchen staff Activities staff It was observed that all of these classifications had their own training requirements in order for these assigned staff to be able to perform and conduct their assigned tasks and duties. A review of the facility personnel records revealed that annual training was completed for all staff providing care and supervision to the residents in care. In addition, additional training sessions were conducted for medication management, personal rights, and reporting requirements. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview