Other·May 4, 2026

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident 2681454. Survey ID: 1DD126-H1 State Citation B was written. REGULATORY VIOLATION(S): Title 42 Code of Federal Regulations § 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Title 22 California Code of Regulations § 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22 California Code of Regulations § 72527(a)(12) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 12/2/25, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Nursing services and Pharmaceutical Services. The facility failed to implement their policy and procedure for one of three residents when Resident 1's controlled medication (medications that are regulated due to higher risk of misuse) Lorazepam (used to treat severe anxiety) with 19 tablets were missing or unable to be located. This failure resulted in Resident 1 missing two doses of the medication and potential adverse health outcomes and violated patient rights. FINDINGS: During an interview with Registered Nurse (RN) A, on 12/2/25, at 1:30 p.m., RN A stated he was counting the narcotics (used to treat moderate to severe pain) in the Station 2 medication cart with the night shift nurse (RN B) on 11/30/25. RN A stated he could not find a bubble pack containing the medication named Lorazepam (a controlled medication used to treat severe anxiety) 0.5 milligrams (mg, unit of measurement) for Resident 1. RN A stated three medication carts, and 48 resident rooms were checked but they could not find the medication. RN A called the pharmacy for a replacement of the medication and received the replacement on 12/2/25. RN A confirmed Resident 1 missed two doses of the medication Lorazepam tablet 0.5 mg give 1 tablet by mouth one time a day on 11/30/25 and 12/1/25 at 9 a.m. During an interview with RN B, on 12/2/25, at 1:52 p.m., RN B stated she worked the night shift on 11/29/25. RN B confirmed all narcotic medications were accounted for at the beginning of her shift on 11/29/25. At the end of RN B's shift on 11/30/25, around 7 a.m., RN B stated that RN A noticed a bubble pack of Lorazepam was missing during the count of the narcotics. RN B stated the narcotic record book for Resident 1's Lorazepam indicated there were 19 tablets remaining. RN B looked for the missing medication with RN A but were unable to locate it. RN B stated she did not know how the medication went missing during her shift. During an interview with RN C, on 12/23/25, at 3:53 p.m., RN C confirmed he was working the evening shift on 11/29/25 prior to RN B's shift. RN C stated all narcotics were accounted for during the count with RN B. RN C confirmed Resident 1's Lorazepam medication was counted during the count at the end of the shift with RN B. RN C and RN B signed the narcotic book indicating no medications in the medication cart was missing. During an interview with the Minimum Data Set Coordinator (MDSC), on 12/2/25, at 12:34 p.m., the MDSC stated she found a torn label of a medication at the bottom drawer of a bedside table in an empty resident room. The MDSC confirmed the label was from the missing medication of Resident 1. The MDSC stated the 19 tablets of Lorazepam were not found. During a concurrent interview and record review with the Director of Nursing (DON), on 12/2/25, at 12:50 p.m., the DON confirmed RN B and RN C signed the narcotic record book on 11/29/25 indicating all narcotics were accounted for. The DON stated Resident 1's Lorazepam medication with 19 tablets was accounted for on 11/29/25. The DON confirmed Resident 1's Lorazepam medication was missing during RN B's night shift on 11/29/25. The DON also confirmed the torn label found was part of the bubble pack of Resident 1's missing medication. The DON confirmed that the 19 tablets of Lorazepam was not found. Review of the facility's policy and procedure (P&P), titled Controlled Substances, dated 4/19, indicated "Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift...Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together..." Review of the facility's P&P, titled Resident Rights, dated 12/16, indicated "Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from...misappropriation of property..." Review of the facility's P&P, titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, dated 14/17, indicated "Residents have the right to be free from theft and/or misappropriation of personal property..." The facility failed to implement their policy and procedure for one of three residents when Resident 1's controlled medication (medications that are regulated due to higher risk of misuse) Lorazepam (used to treat severe anxiety) with 19 tablets went missing or unable to be located. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.