Complaint Investigation Report

Allegation: “Staff did not dispense medications as prescribed”, it is being alleged that the facility has made medication errors. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff agreed with the allegation. Interviews conducted with W1 revealed the following: 1 out of 1 witness agreed with the allegation. UIRs for Resident 1 (R1) and Resident 2 (R2) revealed the following: On 1/3/2026, R1 received R2’s medication in error; R2 did not receive their noon medication as prescribed; the facility contacted R1’s and R2’s responsible party, physician, hospice, facility staff, and retrained staff who committed medication error. Progress Notes for R1 and R2 revealed the following: On 1/3/2026, facility staff conducted an investigation and found that R1 was provided with two medication tablets that belong to R2 during noon time, and R2 did not receive their scheduled noon medication. Staff trainings revealed the following: The staff who committed the medication error was retrained on “Skills Evaluation-Medication Assistance” dated 1/7/2026. The facility retrained staff on “Annual Medication Training” on 1/21/2026. Substantiated: Based on interviews and records reviewed, 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 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a plan of correction was developed. Appeal Rights and a hard copy of this report were provided to General Manager, Tracey Mallaret.