complaint·October 28, 2025

On the allegation, facility staff did not provide resident’s medication as prescribed. It was alleged that during Resident #1’s (R1’s) stay at the facility they were not provided with medications as prescribed by their primary care physician (PCP). Record review revealed R1 moved into this facility on 9/19/2024. R1’s physician orders as of 9/22/2024 reveal R1 was prescribed the following medications: Alpha lipoic acid 600mg one tablet by mouth daily; brimonidine tartrate ophthalmic solution 0.2% one drop into affected eye two times daily; brimonidine tartrate-timolol ophthalmic solution 0.2-0.5% one drop ophthalmically into affected eye two times per day; gabapentin capsule 300mg one capsule orally three times per day; oxybutynin chloride 5mg one tablet orally two times per day; quetiapine fumarate 25mg one tablet by mouth in the morning and two tablets by mouth at bedtime; sertraline 25mg one tablet orally daily; tramadol 50mg one tablet by mouth twice daily; trazadone 50mg one half tablet by mouth at bedtime. The facilities Centrally Stored Medication and Destruction Records (CSMDRs) for R1 list all the medications above except for the alpha lipoic acid prescribed on 9/22/2024. The CSMDRs list gabapentin 300mg filled on 1/2024 with a quantity of 90 and started on 9/19/2024. Records show R1’s PCP sent orders for the alpha lipoic acid and gabapentin to the pharmacy on 10/11/2024, these are not listed on the CSMDR. The facility staff could not provide documentation showing the alpha lipoic acid was ever given as prescribed. The facility could not show documentation of the gabapentin filled on 10/11/2024 was given as prescribed after running out of the medication on hand started on 9/19/2024. R1 moved out of this facility on 11/10/2024 indicating R1 went approximately 22 days without gabapentin from 10/20/2024 to 11/10/2024. Interviews revealed when R1's PCP wrote a new medication order it was sent to JDX pharmacy, JDX pharmacy fills the order and delivers the medication to the facility. Licensee stated they do not know why they do not have documentation of these medications and realizes they should have ensured medications were given as prescribed. Interview and record review reveal R1’s PCP changed their trazadone order to 100mg one tablet by mouth at bedtime on 10/11/2024 and their quetiapine fumarate to 200mg one tablet by mouth at bedtime on 10/08/2024. The facilities Centrally Stored Medication Record (CSMDR) for R1 does list these changes to R1’s medications. LPA verified the remaining medications listed on all CSMDRs received, and all records were found to be accurate. (Continued on LIC9099-C) On the allegation, staff violated resident’s personal rights. It was alleged that facility staff would yell at Resident #1 (R1), “get back in your room,” push R1 back in their room, and take R1’s hearing aids, wheelchair, and walker away from them. It was also alleged that facility staff had a catheter placed in R1 because they did not want to change R1. Regarding R1’s catheter, LPA record review and Interviews reveal that on 10/18/2024 a foley catheter was placed in R1 by a home health nurse with an order from R1’s primary care physician (PCP). The catheter was placed due to staff reporting that the resident had not urinated in approximately 8 hours. On 10/9/2025 LPA attempted to interview R1 and was unable due to their current medical conditions. Regarding staff mistreatment of R1, LPA interviews revealed one witness who heard staff raising their voice at R1 while speaking with R1 over the phone. Additional visitor interviews revealed no observation or hearing of staff mistreating the residents or taking their personal devices. Staff interviews reveal that sometimes they need to raise their voice to be heard by residents, but they do not yell at them in a mean way, push them or take their things. Resident interviews reveal that staff have raised their voice when residents are hard of hearing, but residents have not heard or witnessed staff ordering residents around or taking their personal devices from them. Although the evidence obtained during this investigation did not meet the threshold for a citation, the facility has a history of similar complaints regarding staff interactions with residents and visitors, suggesting an ongoing concern that the licensee is encouraged to monitor and address. LPA reviewed Title 22, Division 6, Chapter 8, Article 08, regulation 87468.1(a)(1); “ Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.” Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation, staff did not safeguard a resident’s personal belongings. It was alleged that after facility staff took R1’s hearing aids from them the hearing aids were never found. Review of a physician report dated 1/30/2024, approximately eight months prior to R1 moving into this facility, states R1 has hearing aids for auditory impairment and the report was signed by a physician R1 had been seeing for approximately six months. A physician report dated 10/23/2024 states R1 does not have auditory impairment and was signed by a different physician who R1 had been a patient of for approximately two months. (Continued on LIC9099-C) Interviews revealed that Staff #1 (S1) conducted the preplacement assessment of R1 at R1’s previous place of residence prior to moving into this facility. S1 stated that they never saw any hearing aids during visits to R1’s previous residence, no one ever mentioned hearing aids at the time and when R1 moved into this facility no hearing aids were documented or seen in R1’s personal belongings. Review of R1’s Resident Personal Property and Valuables (RPPV) form reveals a list of approximately 27 of R1’s personal items brought to the facility on the day they arrived, 9/19/2024. Hearing aids are not listed on R1’s RPPV. Interviews revealed the missing hearing aids were found on 12/20/2025 in a box of R1’s personal belongings that was moved with R1 out of this facility to their new place of residence on 11/10/2024. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated . On the allegation, staff did not assist resident with medical appointments. It was alleged that the facility was not taking R1 to their physician appointments, including the eye doctor. R1 moved into this facility on 9/19/2024. Staff interviews reveal that when R1 moved into the facility they had previously seen a different PCP, R1 wanted a new PCP, and facility staff helped R1 find one. Review of Central Coast Home Health and Hospice (CCHH) records for R1 reveal a referral for home health nursing was sent to CCHH by R1’s new PCP on 9/22/2024. R1 was seen by a home health nurse approximately 5 times while in care at this facility. On 10/9/2025 LPA attempted to interview R1 regarding their medical care while at the facility but was unable due to their current medical conditions. Staff stated they attempted to contact R1’s eye doctor but were unable to schedule R1 an eye appointment before R1 moved out of the facility on 11/10/2024. Based on all interviews conducted and documents obtained, at this time the above allegation was found to be unsubstantiated , meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, report signed, and report provided to Licensee/Administrator Dexter Price . Based on all interviews conducted and documents obtained, since the facility did not provide R1’s alpha lipoic acid and gabapentin as prescribed, at this time the above allegation was found to be substantiated, there is a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted, deficiencies cited on LIC9099-D page, report signed, appeal rights and report provided to Licensee/Administrator Dexter Price .