The investigation revealed regarding allegation: Staff did not dispense medications as prescribed. It is alleged that facility staff would force him to wake up in the middle of the night to take his pain medications. LPA interviewed seven (7) staff and five (5) of seven (7) staff denied the allegations. One staff member stated that staff would enter resident’s room in the early morning hours after knocking on resident’s door to administer resident’s medication. Staff stated staff were asked by resident to enter resident’s room to administer resident’s medication in the early morning hours. One former staff member stated that the facility was instructed by the resident to enter resident's room and administer resident’s medication in the early morning hours. Staff stated resident would change mind often and get angry at staff if staff did not administer resident’s pain medication during the middle of the night. LPA interviewed ten (10) residents and nine (9) of (10) residents could not corroborate the allegations. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not ensure medications were properly managed. It is alleged that facility would run out of resident’s PRN medication and resident would have to go without it for days at times.

LPA interviewed Seven (7) staff and all seven (7) staff denied the allegations. LPA interviewed ten (10) residents and seven (7) of (10) residents could not corroborate the allegations. A few residents stated that very seldom, their medications are delay, but have never missed a dose. LPA reviewed residents MAR for 07/2025, 08/2025, and 09/2025 and did not find any discrepancies on the forms for the three months reviewed. Resident received PRN medications for those months. LPA reviewed residents progress notes from March 2025 – October 28 2025 and one note mentioned staff calling resident MD for refills. No notes showed resident running out of PRN oxycodone or other medications. Several staff stated that the facility would contact resident’s physician when refills were needed, but that at that time the physician would not fill the controlled substances right away and may cause slight delay which was out of facility’s control. There is insufficient evidence to substantiate this allegation.

(Continued on 9099C)

Allegation: Staff did not allow resident to be re-admitted to facility. It is alleged that staff had resident referred to 5150 psychiatric hold and did not allow resident to return. Resident has resided at Savant of Alhambra since 12/11/2024. On 10/09/2025 resident was allegedly angry and threatening staff. Staff called Los Angeles County psychiatric team and was sent to Los Angeles Downtown Medical Center and placed on a 5150 psychiatric hold. A few days later a staff member was sent to skilled nursing facility (SNF) (Green Acres) to reassess resident to admit resident back to facility and staff determined resident required a higher level of care. On 10/28/2025, staff went to the SNF per resident’s request to obtain residents personal belongings. During the visit, resident signed Acknowledgement of Discharge form dated 10/28/2025. That shows resident vacating self from facility while acknowledging receipt of resident’s belongings. A staff staff member stated that the SNF could not accept the belongings of resident due to space and facility took resident’s belongings back to facility and then to storage facility on 01/09/2026. Resident’s relative acknowledged all of resident’s remaining belongings were received and signed a document dated 01/09/2026. Resident has remained at SNF since resident was placed on 5150 hold back on 10/09/2025. At of the time of this report, the resident continues to reside in the SNF. This is evidence that the resident requires higher level of care. The evidence shows that facility cannot readmit resident since resident requires higher level of care. This is also documented by resident's doctor. There is not enough evidence to substantiate this allegation.

Based on interviews with staff and residents and records review, the information obtained during the investigation is insufficient to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.