Complaint Investigation Report

On the allegation " Facility mismanaging residents medications" and " Facility not keeping accurate medication records/log" LPA observed that the medications for R1, and R2 are being mismanaged. LPA observed medication counts for R1 were off. LPA observed a prescription for R1 that stated for them to take 1 tablet daily had a half tab and staff where unable to explain why. ED states that R1 used to manage their own medication however when the facility took over the proper procedure may not have been done to ensure that the counts were correct. LPA also observed several duplicate medications for R1 that were being used simultaneously when the excess should have been stored in over-flow. LPA also observed that at approximately 1:00pm that R2 had not been administered any of their morning medications. LPA also observed that the proper documentation was not done in the E-MAR as to why the medications were not administered. Through interviews with staff LPA found that they were not familiar with how to properly document medication refusals/ late administration or familiar with medication administration procedures. ED states that they had already identified that staff needed additional training and that it is scheduled for March 9-11 2026. Therefore the allegations "Facility mismanaging residents medications" and "Facility not keeping accurate medication records/log" are Substantiated.

***Civil Penalties assessed for $250 for repeat violation in 12 month period***

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.