Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not dispense residents' medication as prescribed.

It was alleged that facility staff failed to dispense residents' medications as prescribed, as multiple prescribed medications appeared unused for extended periods, and residents experienced untreated medical conditions and panic attacks despite active medication orders.

On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs provide medications to residents. A1 stated the facility contacts the pharmacy for refills when a resident's medication runs out or needs to be refilled. A1 stated medtechs follow the prescription order when a resident requests a PRN medication like Ativan. A1 stated medications are documented both electronically and manually when administered to residents.

On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes the residents are not getting their medication as prescribed. 3 of 7 staff denied the allegation and stated medtechs provide medications to residents and document using QuickMar or a laptop, and medtechs follow the prescription order for PRN medications like Ativan. 3 of 7 staff were unaware of the allegation and stated they are not medtechs so they do not administer medications, but they notify the medtech when a resident requests PRN medication.

On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they do not get their medicine every day when they are supposed to, sometimes staff do not give them medicine, and they have asked for medicine and not gotten it. 1 of 10 resident did not confirm nor deny the allegation and stated they try to get medicine but sometimes forget. 6 of 10 residents denied the allegation and stated they get their medicine every day when they are supposed to, staff give them medicine when needed, and staff put cream or ointment on their skin when it itches.

On 02/20/2026 between the hours of 3:38pm - 3:50pm, LPA conducted a record review and observed the following: From October 2025 through January 14, 2026, LPA observed a failure to dispense medications as prescribed. The "Exceptions" and "Pass Notes" logs documented hundreds of missed doses, primarily attributed to a persistent pattern of "Resident Refusal." Many of these refusals occurred because staff failed to administer medication when the resident was asleep, with staff documenting that they "didn't wanna wake up" the resident or that the resident believed "sleep is more important." The Medication Administrator Record showed the failed to maintain an adequate supply of medication, with numerous entries citing medications as "pending delivery," "awaiting RX refill," or "not in cart" for consecutive days. Per the resident's primary diagnoses of Heart Failure and Chest Pain, medications like Furosemide, Bisoprolol, and Losartan—as well as psychiatric medications like Sertraline for anxiety—were routinely omitted for weeks at a time.

Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights.