complaint·March 24, 2026

The allegation is that resident R1's medication M1 was unable to find in the medication cart and medication M2 was not applied to resident R2. On 01/28/2026, LPA interviewed Health Service Director (HSD). HSD stated he/she joins the facility on 01/05/2026. HSD stated at that time the previous Health Service Director already left the facility. HSD stated the caregivers and Med Tech also kept leaving the facility before and after he/she joined the facility. HSD stated he/she brings a new Med Tech team to the facility. HSD stated the previous Health Service team is not good at documentation and maintenance of documents. LPA interviewed a staff (S1). S1 stated he/she just joined the facility. S1 stated he/she spent a lot of time to do documentation and to maintain the facility documents. S1 stated the previous team did not keep good documentation. LPA interviewed a staff (S2). S2 stated he/she just joined the facility. S2 stated many Med Techs left the facility recently. S2 stated he/she did not see resident R1's medication M1 in Med Cart, but he/she found R1's medication M1 in the Med Room. LPA interviewed Executive Director (ED) Erika Holtman. ED stated he/she just joins the facility for 10 days. ED stated for resident R1's medication M1, the doctor order is to start medication M1 from 10/16/2025, and can stop after 3 weeks if ineffective. ED stated so after 11/6/25 it is fine to stop M1 for R1 if ineffective. ED stated the previous management team might already communicate with R1's doctor regarding medication M1 to stop but the new management team is unable to find the document. ED stated the new management team requested R1's doctor to issue a doctor order in writing to discontinue R1's medication M1 because the facility cannot find the document, but R1's doctor just replied to follow the doctor's order. ED stated the facility issued a second request for doctor order to discontinue R1's medication M1. ED stated R1's doctor issued a doctor order to discontinue R1's medication M1 on 01/20/2026. ED stated resident R2 always refused medication patch M2 and claimed R2's private nurse has agreed with that R2 not to use M2 patch. ED stated the new management team requested R2's doctor to issue a doctor order to discontinue medication M2 for R2 because R2 always refused to use it. ED stated on 01/23/2026, R2's doctor issued a doctor order to discontinue R2's medication M2. Continue on LIC9099-C. Page 2 of 4. LPA interviewed resident R1. R1 stated there is no problem for his/her medications. LPA interviewed R1's spouse (FM), roommate of R1. FM stated there is no problem for the administration of R1's medication. FM stated he/she has no complaint against the facility. LPA interviewed R1's another family member (FM1). FM1 stated there is no problem for R1's medication administration including medication M1. FM1 stated medication M1 is not necessary to R1. FM1 stated R1 does not need medication M1 every day. FM1 stated he/she always takes R1 for R1's doctor appointments. FM1 stated he/she contacted R1's doctor many times. FM1 stated he/she communicated with R1's doctor regarding R1's medication M1. FM1 confirmed that R1 does not need medication M1 every day. FM stated for R1's medication M1, it is just a communication issue of the facility. FM1 stated it is not a missing of administration of medication M1 to R1 issue. FM1 stated he/she is unsure if it is the documentation issue because the facility management team had changed. LPA interviewed resident R2. R2 stated the medication M2 patch is very inconvenient. It is hard to adhere to body. R2 stated he/she does not like it. R2 stated he/she already has the prescription for the similar medication cream and is applied every day. R2 stated he/she refused medication patch M2 many times. R2 stated his/her private nurse agrees that he/she can just uses the similar medication cream and does not need to use medication M2 patch. R2 stated he/she and his/her private nurse already talked to the facility staff before. R2 stated it is a communication issue, not a missing administration of medication M2 issue. Based on review of the doctor prescription of R1's medication M1, it specifies to start on 10/16/2025, and is okay to discontinue after 3 weeks if ineffective. Based on the review of R1's doctor order on 01/20/2026 which responding to the facility 2nd request, specifies R1's medication to discontinue on 01/20/2026. Based on the review of resident R2's doctor prescription, resident R2 has similar medication cream M3 and resident R2's medication M2 is to stop on 1/28/2026. Based on the review of R2's doctor order dated 01/23/2026 which respond to the facility request, R2's Medication M2 was discontinued on 01/23/2026. Continue on LIC9099-C. Page 3 of 4. Based on the review of the Medication Administration Records in December 2025 and January 2026 of residents R1 and R2, R1 refused M1 many times and R2 refused M2 many times. R1's medication M1 was safeguarded and found in the facility medication room. The Department has completed the investigation of the above allegation. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted with ED. The report was provided to ED for review. A copy of the report was provided to ED.