complaint·August 12, 2025

Continued from LIC 9099 Throughout the course of the investigation, LPAs reviewed all documents obtained and conducted medication audit. The following was then determined: Regarding allegation of “Staff are not dispensing medication as prescribed” it was alleged that resident medications were not being administered as scheduled, and this has resulted in the resident exhibiting aggressive behavior towards others. Furthermore, the Responsible Party (RP) stated that staff have been crushing Resident #1’s (R1) medication without a physician’s prescription. Interviews conducted with morning Med-Techs staff revealed that there are currently no residents refusing medications. The Med-Tech assigned to the Meadows (Memory care unit) stated that approximately one month ago, R1 had changes to two (2) of their prescribed medications. Staff also stated that R1's medication is currently being administered in a crushed form. LORazepam 0.5 mg to be given as routine medication and not as a PRN and QUEtiapine (generic for Seroquel) changed from 25 mg to 50 mg on 07/17/2025. During the course of the investigation, LPAs conducted a medication audit and reviewed Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Records (MARs), physician’s orders and pill count for R1. The following was observed, medication QUEtiapine 25 mg, 1 tablet two (2) times a day at 8 AM and 8 PM and also give one (1) every 12 hours as needed, was filled and given for the first time on 08/04/2025 with a starting quantity of one hundred and twenty (120). At the time of the audit, one hundred and four (104) pills remained in the medication container for QUEtiapine 25 mg. Based on medication count and interview with Med-Tech, staff continued administering 25 mg medication instead of the 50 mg that was prescribed on 07/17/2025. Additionally, the documentation review revealed that LORazepam 0.5 mg recorded as being administered daily at 8 P.M. on both the CSMDR and the MARs. However, on the Controlled Drug Record, the same employee who initialed the MARs documented the administration time as 5 P.M. It is therefore inconclusive what time the medication was actually given. Furthermore, LPAs observed discrepancies in the documentation for Atorvastatin 40 mg. The refill date on the medication label was 05/17/2025 and the “opened date” recorded by staff was 05/05/2025. Continued on LIC 9099-C Continued on LIC 9099-C LPAs requested documentation reflecting the date that LORazepam 0.5 and QUEtiapine 50 mg were changed from a PRN (as needed) medications to scheduled/routine medications, as well as documentation showing that R1 has a physician’s prescription authorizing their medication to be crushed. Med-Tech staff were unable to locate or provide the requested documentation at the time of the visit. Based on interview and record review, the preponderance of evidence standard has been met; therefore, the allegations above are deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. As this is a repeat violation of the same regulation 87465(a)(4) within 12 months a civil penalty in the amount of $250 for a repeat violati on is being assessed on the attached LIC 421FC. The Administrator, Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.