Complaint·October 7, 2025

Staff interviews revealed the facility has a policy to provide residents with their medications as timely as possible but with a window of one hour before and one hour after the scheduled time. Staff stated it is known that medications for Parkinson’s disease should be given on time per the physician’s order to avoid worsening symptoms. The physician order for R1’s carbidopa-levodopa states it is to be administered at 2:00am, 5:00am, 7:30am, 11:30am and 3:30pm. Interviews revealed on one occasion staff did not bring R1 their morning medications. R1 notified staff to remind them and when staff brought R1 their medications, staff also left a cup of medications in R1’s room intended for another resident. R1 returned this medication to facility staff. Other residents interviewed stated they have not had medications left in their room intended for another resident, and staff interviewed are not aware of a time medications intended for one resident were left in another resident’s room. Interviews and record review revealed there was a day in July 2025 when R1 used their pendant to remind the medication technician on duty, Staff #1 (S1), for their carbidopa-levodopa scheduled at 5:00am. R1 went looking for S1 and found S1 sleeping on a couch outside the medication room on the second floor. After R1 woke up S1, S1 provided R1 their medications. A verbal warning given to S1 was documented by the Administrator and after additional disciplinary actions for other reasons S1’s employment was terminated by the facility. During staff interviews one other staff member admitted they administered R1’s medication scheduled at 2:00am approximately 75 minutes after 2:00am, and an additional interview confirmed this. Resident interviews revealed there have been times when they did not receive their medications timely and they needed to alert staff to remind them they had not received their medications at the scheduled time. Record review revealed the facility medication technicians are not current on the required medication training per California Health and Safety Code. This was addressed during the facility annual inspection conducted by the LPA during the same visit. (Continued on LIC9099-C) Based on all interviews conducted and documents obtained, at this time the above allegation was found to be substantiated , due to staff delaying the administration of time sensitive medication with specific hours of administration scheduled by the resident’s physician. Exit interview conducted, deficiency cited on LIC9099-D page, report signed, and report provided to the Administrator.