Regarding: Staff is mismanaging residents' medications.

It is alleged that staff documented in the system that bedtime medication was given to resident; however, resident was not at the facility to receive their bedtime medication due to being on an outing. It is also alleged that resident’s bubble packs were observed with the bedtime medication popped and that staff did not know where the medication went or if it was thrown away.

Interview with S1 revealed that S1 received a report from S3 that R1 did not receive their bedtime medication after returning from a trip outside of the facility on 3/24/2026. S3 who came on shift after S2 ended their day, informed S1 that when R1 and their responsible party returned from an outing on 3/24/2026 at about 11:30 p.m., they approached the med-tech room to have staff provide R1 with their bedtime medication. S3 indicated that the bedtime medication appeared to have been already popped and given to R1 by S2 when cross check was conducted on the Medication Administration Record (MAR) by S3. S1 indicated that S3 informed S1 that when checking the MAR, it was noted that R1 had already been given their medication by S2, even though R1 was not at the facility during the bedtime medication pass was conducted. S1 indicated that they spoke to S2 on 3/25/2026 and was informed that S2 acknowledged “popping” R1’s bedtime medication and documenting on MAR ahead of time thinking that R1 was at the facility. S2 informed S1 that R1’s medication was placed in a medication cup but was unable to recall where the medication went. S1 stated that removing medication from bubble packs ahead of time is not appropriate practice for medication management and conducted on the spot training with S2 during audit of R1’s medication. LPA attempted to interview S2 and S3; however, they did not return LPA's calls. LPA conducted random review of medication and found, R2 has discontinued Rx-Furosemide 40 mg no longer administered but still listed on MAR. Based on interviews, observations and record reviews the allegation that staff mismanaged resident’s medication is corroborated.

***Continues on LIC 9099-C page 2***

It is alleged that the facility does not keep the facility doors locked in the evening and there is no supervision and anyone is able to walk into the building at 11:30pm at night. It is also alleged that facility staff did not inform Person 1 regarding the new concierge.

Interview with S1 stated that facility’s doors are locked from the outside starting at 10:00 p.m. to 6:00 a.m., daily and entry can only take place when the facility is alerted of people wanting to come in via call button on the front door. S1 revealed that as of 3/25/2026, the facility no longer has a concierge service 24 hours a day which required a staff member to be posted at the front desk of the main entrance during the night shift. S1 indicated that moving forward, the main entrance to the facility will be inaccessible at 10:00 p.m. which will now require visitors to push the alert button on the front door to alert staff to grant access to into the facility. No one will be posted in the front desk to open and staff on shift working the floors will be assigned to monitor the call button alters coming from the front door to grant visitor access. S1 indicated that the new concierge hours have taken effect and that Information regarding the new policy was sent via email blast to resident families and flyers were provided to residents by hand. Interviews with (16) out of (17) people stated that they feel safe in the facility or and not received reports of people not feeling safe in the facility. However; interviews indicated that they didn't know and were not informed about the changes in the hours of facility’s concierge service and that the facility should have informed them of the changes. People further indicated that resident responsible parties have not received information from the facility regarding the changes. Interviews corroborate the allegation that the facility did not adhere to company policy.

Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted with Maria Quiroz, and a copy of this report, 9099-D and Appeal rights was provided.