Complaint Investigation Report

Allegation: Staff mismanage resident's medication. It is alleged that on June 22, 2025 staff (S1) dropped R1's medications, but reported that the resident slapped the medications off of their hands. According to information obtained, S1 has recently been observed dropping medications during medication pass and when opening the medication bubble pack. Staff (S1) denied dropping medications on 6/22/2025, and stated that R1 was given the medication cup, and as the resident reached out to grab the medications they knocked the medications off onto the floor. Staff (S1) stated they picked up the medications and placed them in a bag to be destroyed, documented on the Medication Administration Record (MAR), and administered the same medications from a later date. A total of nine staff were interviewed. Staff interviews revealed that most of the medication pill drops are accidental due to resident's dexterity ability. During the course of the investigation, record review revealed that on 7/13/2025, resident (R2's) medications fell from the medication cup onto the floor because R2 placed the pills in to their mouth quickly. Staff administered medications from a later date, and medication replacement was ordered. A third medication incident was reported today. The incident report alleges that yesterday (7/16/25), R2's medication pill fell on the floor, and S2 picked up the medication and administered the contaminated pill. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Staff do not keep the facility free of pests. The complaint alleges that the July 5, 2025, night shift staff failed to observe ants on resident (R2's) bed, body, and floor. According to information obtained, at approximately 6:20 AM, staff observed ants on R2's feet and arms, and when they checked the resident's room they saw ants all over the resident's bed, as well as an ant trail coming from the hallway. Staff interviews confirmed the incident. Administration staff stated the facility has ongoing pest control services in place, and places work orders if issues are observed. Staff stated they have observed ants in the kitchen area, hallways, and the isolated incident in R2's room. Administrator placed a pest control work order on 7/7/2025, and Dewey Pest Control personnel treated the facility on 7/11/2025. Picture evidence was obtained. It depicts ants all over R2's bed comforter, mattress pad, and along the wall baseboards. There is sufficient evidence to corroborate the allegation.

Based on document review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview was conducted with Administrator and a copy of appeal rights and report was issued.