The complaint alleged that staff members were not providing medication on time, with residents often receiving it hours after the scheduled times. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED), who denied the allegations. During the same time frame, LPA also interviewed a Medication Technician (MT), who also denied the allegations. The MT explained that medications should be administered 1 hour before or after the scheduled time. However, MT consistently tries to deliver residents' medicines on time. In emergencies, a delay may occur, but it should not exceed 1 hour from the scheduled time. Additionally, during this period, LPA interviewed a staff member (S1/MT), who also denied the allegations, stating that the staff are familiar with the residents and ensure that medications are administered in a timely manner.

Later that day, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents (R1-R5). Four of the five residents denied the allegations, stating that the facility provided their medications on time and that they had never encountered any problems. They also mentioned that the MTs were very helpful with their medication needs. Furthermore, the LPA reviewed the Medication Administration Records (MARs) for all five residents (dated October 1, 2025) and found no discrepancies concerning any of the residents' medications.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Report Continued on LIC9099C

The complaint alleged that the facility provided the residents with non-prescribed medications, such as supplements and Tylenol/Aspirin. On 10/27/2025, between approximately 10:00 AM and 12:30 PM, the LPA Richard interviewed the AED, who denied the allegations. On 10/27/2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the MT, who denied the allegations and emphasized that they are very thorough in administering residents' medications. There is no way they would give a resident PRN medications without a doctor's orders. Even over-the-counter medications require a doctor’s order. MT also stated that we do have some residents who are prescribed PRN medications as needed by their doctor.

Furthermore, the LPA interviewed one staff member (S1/MT), who denied the allegation and stated that S1/MT continuously checks a doctor’s orders for any medications received from the pharmacy; without a doctor’s orders, we would not give the resident the medicines.

On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R1-R5) denied the allegations and stated that their doctor did prescribe them pain medications. Furthermore, the LPA examined the 1-month Medication Administration Records for five residents (dated October 1, 2025) and found that four residents are currently taking PRN medications.

Report Continued on LIC9099C

Allegation #3: The Facility did not provide proper notification to the authorized representative for the fee increase.

The complaint alleged that the facility's family member fees increased from $400 to $ 1,600 after management took over without notifying them. On October 27, 2025, from approximately 10:00 AM to 12:30 PM, LPA Richard interviewed the Assistant Executive Director (AED). During the interview, the AED denied the allegations and explained that when the administration raises a resident's care level, the facility must conduct a new pre-appraisal to assess the resident's care needs. If a resident's level of care changes, they will receive a different care rate, which will be communicated in writing.

Additionally, the AED pointed out that the facility's admission agreement states that fees will increase annually. The responsible party will be notified in writing of any fee increase at least 2 months in advance, including the reason for the increase and a general description of the additional costs involved. The AED also mentioned that the facility would send a certified letter to the responsible party for these changes. On 10/27/2025, between approximately 1:30 PM and 2:30 PM, the LPA interviewed five residents. All five residents (R1-R5) stated that their responsible party would know all about it, because they are not the ones writing the checks.

Report Continued on LIC9099C

Based on the LPA observations, interviews, and record reviews, the Preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated

No deficiency cited.

An exit interview was conducted. A copy of the report was provided to the Assistant Executive Director Anna Martinez.