complaint·October 1, 2025

medication to R1. When asked why, S2 told S1 that there was an order and a paper medication administration record (MAR). Every Med Tech after 9/6/2025 also administered the medication, but they used the narc count sheet to track administration instead of the paper MAR. No other Med Tech saw a prescription order. According to the LIC624, the administration of this medication came to the attention of management when S1 received a call from a pharmacy asking why staff requested a refill for a medication that was not on R1’s medication list. The internal investigation revealed that staff were alternating administration of R1’s pain medication between the prescribed pain medication that he was already on and the medication with no order. On 9/13/2025, S3 administered both pain medications at once, according to the narcotic count sheet and electronic MAR. When discovered by management, they informed R1’s family and doctors. On 9/29/2025, LPA Lindstrom spoke with S1 about the incident reported in the LIC624. S1 stated that they asked S2 why they began to administer this pain medication. S2 reported that she had seen an order for the medication and so created a paper medication administration record. S1 has since reviewed the document that S1 referenced and determined that it was not an order. S2 told S1 that they contacted R1’s primary doctor, who confirmed that they had not written the prescription, and then contacted the doctor listed on the medication bottle, who did not respond. S1 stated that the found medication had been prescribed to R1 by a surgeon on 7/16/2025. S1 was unsure how the bottle came to be in R1’s room. The medication bottle contained fourteen tabs when it was removed from R1’s room. Staff administered these fourteen tabs to R1 between 9/6/2025 and 9/17/2025. Based on the LPA’s interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Emily Parker and a copy of this report was provided, along with appeal rights. throughout the day. On 9/13/2025, staff (S3) administered both pain medications during the same medication pass. On 9/29/2025, LPA Lindstrom interviewed two staff (S3 and S4) about the incident reported in the LIC624. S3 stated that they had never heard R1 indicate they felt unwell or symptomatic because of pain medication, nor had they ever thought that R1 needed medical attention for the side effects of pain medication. S3 stated that R1 could be a little sleepy and that they were very insistent about getting their pain medication. S4 stated that when R1 first moved in, they reported not liking how the pain medication made them feel, but then never mentioned it again. S4 stated that they never observed any negative side effects or heard R1 express anything negative about pain medication between 9/6/2025 – 9/17/2025. Based on interviews, observations, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.