Complaint Investigation Report

Per review of Physician’s Report dated May 13, 2025, R1 was diagnosed with Dementia, Atrial fibrillation (AFib), and Osteoarthritis of right knee. R1 was transported to the hospital for labored breathing on January 19, 2026, at 8:50am and returned on January 22, 2026. Hospital records show R1 was referred to cardiothoracic surgery clinic for further evaluation. LPA reviewed the Medication Administration Record (MAR) dated January 2026. R1 was not administered Levothyroxine 25mcg on January 19, 2026, for their 5am dose. LPA reviewed incident report dated January 23, 2026. Per report, R1 was transported to the hospital after 4:21pm on this day, per request of family member. Based on review of MAR, R1 was not administered Levothyroxine 25mcg on January 23, 2026 at 5am. LPA interviewed 4 staff. Staff #4 (S4) reported that they administered Levothyroxine 25mcg on January 19 and January 22, 2026, but they did not initial the MAR. Three out of four staff interviewed reported that they always complete the MAR right after medication is administered. R1’s MAR shows that R1 did not receive Levothyroxine 25mcg on January 19 and January 23, 2026.

Based on evidence gathered, the preponderance of evidence has been met, therefore, the above allegation is found to be Substantiated . Violations are being cited per Title 22 of California Code of Regulations. See LIC9099-D for cited deficiencies.

An exit interview was conducted with the Manager and a copy of this report, (LIC9099, LIC9099-D), and Appeal Rights was provided to the facility representative.