Complaint Investigation Report, 01/16/2026 — Elwyn NC

The investigation revealed the following: regarding the allegation “Staff did not give resident medication.” It is alleged staff did not administer C3 their medication on 10/25/25 and 10/26/25. During record review, LPA Ramirez observed Eastern Los Angeles Regional Center Vendor Special Incident Report (dated 10/29/2025), which indicated that on 10/27/25, staff reported to S2 that C3 was not administered their scheduled prescription of Diltiazem 30mg tablet at 12am on 10/25/25 & 10/26/25. This report revealed that S6 logged that they administered C3 their medication however, two (2) tablets of Diltiazem 30mg were observed still in C3’s bubble pack for days 10/25/25 & 10/26/26 for the 12am dosage. Review of C3’s MAR for October 2025 revealed that S6 logged C3’s vitals as follows: 10/25/25- HR- 88 & SBP- 140 and on 10/26/25- HR- 58 *entry appears to be altered* & SBP- 119. Review of C3’s physician orders revealed that C3 has a standing order for Diltiazem 30mg tablet to be administered at 8am, 4pm and 12am and only to be administered if C3’s SBP (Systolic Blood Pressure) is<100 or if HR (Heart Rate) <60*. Staff interviews revealed that based on C3’s physician orders and vitals taken on 10/25/25 & 10/26/25 by S6, C3 should have been administered Diltiazem 30mg tablet at 12am on 10/25/25 & 10/26/25. Interview with S2 and S1 revealed they observed C3’s medication of Diltiazem 30mg tablet still in bubble pack day for 10/25/25 & 10/26/25. LPA Ramirez attempted to interview S6 via telephone but was unsuccessful. LPA Ramirez attempted to interview C1, C2, C4 and C5 however, due to cognitive impairments, LPA Ramirez was unable to gather meaningful responses. C3 was not at the facility and unable to be interviewed.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated .

One (1) type A deficiency has been cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided.