Complaint Investigation Report

LPA gave guidance that the staff should not be introducing obstructions to accessing the emergency exit, the facility should be assessing if it has the necessary staff to meet the needs of the clients instead.

In regard to medication mismanagement, in interviews with staff and clients, a consensus statement was reached that an error was introduced back in late december/early january, where a staff seemingly distributed a PRN medication as a daily medication. As the client had a very limited supply of that medication he was anxious about not having it if he needed it. that staff was let go, since the incident. The facility staff provided that the experinced staff was on vacation leave during this period, but had gone through an extensive medication audit recently where this error was discussed with the ombudsman.

Record review of the MARs by the LPA for the client indicated above had a period of 2 weeks where a drug went from prn to twice daily at some point in late december/ early january, and the majority of days it was not given and some days given at half dose. none of the required documentation exists for distributing it as a prn exists from this two week period.

Staff recalled a second situation that two medications not being refilled causing a gap in medication being delivered as perscribed 3/16/26 to 3/19/26, they brought the med refill issue to pharmacy, who introduced a delay where the doctor had an appropriate amount of time, but the doctor was having trouble signing into his online prescription pad delaying the medication filled and arriving to the pharmacy. LPA asked the staff in that situation to document what thier attempts were and follow up to those attempts. Staff did not take down documentation in that instance, but resolved to do so in the future.

LPA notes these incidents are related to a staff in a situation where there is not significant support from the administrator in the form of scheduling an adequate amount of staff for break relief and not sufficent training in medication administration for the staff. One resident claimed to only have seen the administrator twice in four months.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, is being cited on the attached LIC 9099D.)

Citations are issued as part of this visit. A copy of the report was read and given to the designated signatory of the administrator, a digital copy will be emailed to the address on file. appeal rights provided, exit interview was conducted.