Complaint Investigation Report

The investigation revealed the following:

In regards to the allegation: "Staff did not ensure that resident was administered their medication as prescribed." It is alleged that there was one medication error for C1. According to the Corrective Action Plan (CAP) C1 had a missing 11am medication still in packaged and not dispensed. (4) out of (4) staff interviewed corroborated the allegation. S1-S4 indicated that a medication error was identified and reported for C1 when QA from ELARC conducted a routine FMR (Facility monitoring report) on 01/13/2025. All staff interviewed stated that C1 did not receive the scheduled medication. L PA verified this with S1-S4 during the interviews, who all agreed with the findings in the Corrective Action Plan (CAP) and stated they would comply with it, supporting the allegation.

In regards to the allegation: "Staff did not report an incident involving a resident as necessary." It is alleged that there was a lack of SIR per the medication error for C1. Interview with S1 corroborated the allegation. S1 stated that she worked on the incident report but submitted it to the Regional Center's QA after the deadline. S1 indicated that the incident report should have been sent by 01/20/2025, but S1 sent it on 01/30/2025. Based on the CAP of 01/23/2025 and staff interviews, the allegation has been substantiated.

Based on LPA’s interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Josephine Cochongco, Administrator along with the Appeals Rights.