Complaint·July 8, 2025

Based on review of R1’s physicians report dated 8/9/2024, R1 is unable to administer his/her own medications. On 10/25/2024 LPA Christine Dolores received a voicemail and email from S1 to self-report medication errors. LPA Dolores spoke with S1 who stated the facility was reporting medication errors for 2 residents. S1 stated a plan of correction was being conducted with nurses and medtechs. On 7/8/2025 LPAs Monter and Tarin conducted a random audit of 4 Residents. During audit, LPAs observed medication discrepancies for R8. LPAs observed Medication M1, which states “Take 1 tab by mouth in the morning, before breakfast.” LPAs reviewed Medication M1’s bubble pack and observed the tablet on #8 was still inside the bubble pack. The bubble pack states the medication was opened on 7/1/2025. A review of R8’s Medication Administration Record (MAR) states that R8 was administered M1 from 7/1/2025 to 7/8/2025 at 6:00AM. Based on review of R8’s physicians report dated 12/20/2023, R8 is unable to administer his/her own medications. LPAs interviewed Health Services Director (HSD). HSD stated she was not informed of any refusal by staff. LPAs asked if HSD could explain what occurred. HSD stated, “I don’t know.” During audit of residents R7 to R10, LPAs noted that each resident has medications that were not listed on the Centrally Stored Medication log. LPAs interviewed Health Services Director (HSD). HSD stated “I don’t know. Maybe the med-techs didn’t central log it.” HSD did not provide additional information. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED . California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.