complaint·January 21, 2025

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the disposition. Through statements and document reviews it has been determined that R1 was prescribed Tramadol to be dosed 1/2 50 mg tab at bedtime as needed for pain but was administered 50 milligrams on several occasions in December, 2024, including 12/09, 12/15, 12/22; and some doses were given twice a day at times other than bedtime. Facility Administration has acknowledged the errors and has taken steps to retrain staff and place protocols in place to avoid future errors. Based upon the statements and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.