Complaint·December 29, 2025

W1 states medication administration is being done by ‘non-trained’ staff resulting in medication errors and missing syringes. W1 states he/she did not observe these incidents of medication errors and missing syringes and did not provide information regarding these incidents. On 1/8/2025, 7/11/2025, 8/8/2025, LPAs interviewed 7 Staff (S1 to S7). 5 Out of 7 Staff state he/she has not observed a staff who is not a MedTech in assisting residents with medications. S4 and S7 states he/she has observed staff who are not MedTechs, assisting residents with medications. LPA reviewed 7 staff training records. 6 Out 7 staff have training for medications. Facility did not seek immediate medical care for residents after fa l l W1 states R1 had a fall on June 20, 2024, and the facility called R1’s family and did not seek medical attention. On 1/8/2025, 7/11/2025, 8/8/2025, LPAs interviewed S1 to S7. 6 Out of 7 Staff states the facility seeks medical care for residents after a fall. S1 states staff will notify the MedTech and call 911 or palliative care, depending on the situation. S5 states he/she observed R1 fall on 6/20/2024 and the facility did not seek medical attention, instead the facility called the resident’s loved one. On 8/6/2025 LPA interviewed R1’s Family Member (FM 1). FM 1 states he/she was informed by facility staff that R1 had a fall. FM 1 states R1 fell “due to medication.” FM states he/she does not remember the date of the incident. FM states he/she took R1 to the hospital for assessment and did not have any injuries. FM 1 did not provide additional information regarding this incident. Facility water temperature is too cold W1 alleges the facility’s water temperature is ‘too cold’. W1 states the water temperature on the second floor takes more than 15 minutes to get warm, and water temperature on the first floor takes 10 minutes to get warm. W1 did not provide additional information regarding the dates when these incidents occurred. On 01/08/2025, LPA Madrigal and Marrufo conducted a complaint investigation visit. During visit, LPA Madrigal toured 7 resident bathrooms on the second floor, and 2 resident bathrooms on the first floor. Page 2 of 3 LPA Madrigal tested the water temperature in 9 random resident bathrooms sinks. 9 random bathroom sink water temperatures measured from 108 F to 119 F. Administrator offered medications of a deceased resident to another resident’s family member W1 alleges he/she observed the facility Administrator offering constipation medication of a deceased resident to another resident’s family. W1 did not provide a date when this incident occurred. LPA interviewed 7 Staff (S1 to S7). 6 Out of 7 Staff state he/she has not observed the Administrator offering medication of a deceased resident to another resident’s family member. S4 states he/she overheard the Administrator on the phone offering constipation medication of a deceased resident to another resident’s family member. S4 did not provide additional information regarding this incident. LPA interviewed 7 Family Members (FM2 to FM8). 5 out of 7 FM stated he/she has never been offered the medications of a deceased resident by the Administrator. FM 2 and FM5 declined to be interviewed. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . An exit interview was conducted, and a copy of this report was provided.