Complaint Investigation Report

It was alleged that staff have left the medication room door open and unattended.

On 04/10/25, while investigating an unrelated complaint, LPA toured the medication room, noted the facility has 2 locked options available, both the locking of the door to the medication room, and a lock on the medication cabinet within this room. LPA observed the medication room door locked, but the internal cabinet where medication is kept was unlocked. On 04/17/25 and 07/31/25, LPA observed the medication room to be locked and attended. During the 04/17/25 visit, staff provided a tour and confirmed all cabinets were locked. The medication room door is a Dutch-style door with an automatic lock requiring a key card or medication room specific key. The upper half can open independently for medication dispensing.

LPA reviewed Telecare Policy titled Medication Storage, #MM-2000 which states under “Procedure…4. All drug supplies and medications on site are stored behind two (2) locked doors (keyed room and in locked med cabinet).”

In April, a copier was located in the medication room. Staff stated they believed the door was left open by others accessing the copier. By 07/31/25, the copier had been removed. LPA was also told during 7/31/25 visit that the medication room on occasion is used for medical zoom appointments when no other room is available.

On 05/22/25, 06/03/25, and 07/31/25, lead and management staff reported observing the medication room left unlocked. One noted the upper half of the door was sometimes left open, allowing access by reaching over the locked lower half. On 06/03/25, LPA reviewed a “Manager note” documentation confirming staff were observed leaving the door open on 04/07/25 and 04/08/25.

Based on observation, interviews, and records, the allegation is substantiated. There is a preponderance of evidence that staff left the medication room door unlocked and unattended.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (LIC 9099-D).

Exit interview conducted, copy of report and appeal rights issued.