Complaint Investigation Report

R2’s medication Diclofenac SOD DR 50MG Tab. LPA observed a bubble pack labeled as morning and was observed to have the correct amount was dispensed, the evening bubble pack shows with a start date of 1/15/2026, the bubble pack holds 30 pill, there are three pills left which indicates on one occasion R2 missed or refused their medication, the MARS does not indicate pill missed or refused. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation: Staff are not following resident's care plan as required. LPA reviewed R3 and R4's files which did not have a Home Health Care Plan which indicates there is no plan to follow. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation: Staff are not following reporting requirements as required. Interviews were conducted with staff and residents. R1 had fallen in November 2025 and a report was not sent to the Dept. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies were cited under Title 22. Exit interview was conducted and copy of this report LIC9099, LIC9099D, and appeal rights were provided to Interim Administrator- Vivian Villegas.