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32 | Staff did not prevent the facility from being in disrepair.
During the investigation, the LPA conducted observations of the facility, including multiple resident rooms. During the investigation, the LPA observed multiple resident rooms with broken fixtures and holes in the walls. The observed conditions demonstrated that portions of the facility were not maintained in good repair. The presence of broken fixtures and holes in the walls in multiple resident rooms established that the facility had conditions requiring repair and maintenance. Based on the observations conducted and the evidence obtained during the investigation, the allegation that staff did not ensure the facility was maintained in good repair is SUBSTANTIATED.
Staff did not administer medication as prescribed.
During the investigation, the department reviewed residents' medication records, physician's orders, medication administration records, and other relevant documentation. The investigation identified instances in which medications were administered in a manner that was not consistent with the physician's orders:
R1 was ordered (by their Physician) Melatonin Oral Tablet 3 mg -1 daily at bedtime. Medication was documented as unavailable from 7/1/26-7/8/26; however, MAR records indicated that the same medication was given on 7/1/26 and 7/3/2026.
R2 was ordered (by their Physician) Prednizone Oral Tablet 10 mg - 6 tablets once daily for 5 days. Facility entered the order as 5 tablets once daily for 5 days (Start date 6/13/26 – 6/17/26) which did not match the physician’s order.
R3 was ordered (by their Physician) Calcium Carbonate (elemental) 600 mg- one tablet twice daily. Record review indicated that due to medication not being available, AM staff did not administer on July 6, 7, 8, and 9, 12 of 2026; however, PM staff indicated that medication was administered during the PM shift. PM staff had no explanation regarding this question.
S9 signed off on R1and R3’s Medication record. The RX was given, however during a medication audit, it was found that RX was not present in the facility. When Department asked S9 why R1 and R3’s medications were signed off as given when medication was not present in the facility, S9 had no explanation to give.
The medication records and physician's orders reviewed demonstrated discrepancies between the prescribed medication orders and the manner in which certain medications were administered. The evidence established that some medications were not administered according to the physician's prescribed orders. Based on the documentation reviewed and the evidence obtained during the investigation, the allegation that staff did not administer medication as prescribed is SUBSTANTIATED.
Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/08/2026
Section Cited
CCR
87465(c)(2) | 1
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7 | 87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This was not met … | 1
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7 | The licensee will retrain all medication staff on physician’s orders, medication administration, and accurate MAR documentation. The administrator will conduct medication audits to verify medications are available, administered as ordered, and accurately documented, with corrective action taken for any discrepancies.. |
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14 | Based on record review and interviews, the licensee did not comply with the section cited above by failing to ensure medications were administered according to physician’s orders. Specifically, discrepancies were identified for three (3) residents (R1, R2, and R3), including medication documented as administered when the medication was reportedly unavailable, a medication order entered at an incorrect dosage, and medication documented as administered despite discrepancies regarding its availability. These discrepancies demonstrate that medications were not consistently administered in accordance with physician’s orders, which poses an immediate health, safety, and/or personal rights risk to residents in care. | 8
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Type B
10/14/2026
Section Cited
CCR
87303(a) | 1
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7 | 87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met … | 1
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7 | The licensee will ensure the facility is maintained in good repair by promptly repairing or replacing damaged fixtures and repairing holes in walls. The administrator will conduct routine inspections to ensure the facility remains in good repair. |
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14 | Based on observations conducted during the investigation, the licensee did not comply with the section cited above, as multiple resident rooms were observed with broken fixtures and holes in the walls. These conditions demonstrate that portions of the facility were not maintained in good repair, which poses a potential health, safety, and/or personal rights risk to residents in care. | 8
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