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32 | LPA reviewed R1’s medication records which revealed R1 was physician ordered the medication Quetiapine 25mg was to be given 1 time a day at bedtime then on 07/20/2026 prescription was changed to 50mg at 3pm for sundowning, may advance to100 mg daily after 2 weeks if continuing to have disruptive sundowning. The new medication was listed on the CSMDR and on the MAR according to the orders. The start dates of the old and new medication orders for each bottle were listed and the pill counts of medication at the facility matched the records. LPA reviewed records for Lorazepam Medications the new order from the doctor 07/20/2026 was 0.5mg tab PO BID PRN, to be given by mouth 2x per day as needed, based on the record review the facility never used over the prescribed PRN dosage.
LPA’S interview with witnesses revealed on a visit in the late morning to the facility on 07/23/2026 to assess R1, the staff could not provide correct paperwork or details about medications and R1 seemed to not be at R1’s normal baseline and seemed out of it. Witness stated witness does not know how R1 normally is after receiving medications in the late afternoon or evenings.
LPA interviewed staff 1 (S1) that stated last week it was around the 23rd of July, Staff was not at the facility and said everything should have been documented on the MAR, Staff said R1 had gotten agitated and started displaying sundowning symptoms around 11:00am and it was probably due to R1 not sleeping very well the night before, medication Quetiapine dosage had been increased at the last doctor’s appointment on 07/20/2026 from 25mg to 50mg to help with the new behaviors but on this morning instead of S1 assisting R1 with the medication at 3pm assisted at 11:00am. Staff stated only 25mg was given and per the new order another 25mg could be given later if needed, the new order does say 3pm. Staff had also assisted R1 with medication Lorazepam .05mg ½ tablet at 2:45am and ½ tablet at 1:25pm on 07/23/2026, and that is a PRN as needed from the doctor. S1 said S1 did not call the doctor to get an authorization to assist R1 with medication at 11:00am instead of 3pm, therefore this allegation is Substantiated at this time.
On the allegation: Staff did not provide proper supervision, had resident watch another resident in care. LPA received a statement from a witness that stated on 07/21/2026 on a visit to the facility 3 residents in care were observed, Resident 1 (R1) was in the room with Resident 2 (R2), R2 informed the witness that the caregiver had asked the Resident to oversee R1 while the staff were tending to the needs of another resident in care and had to shut the door for privacy leaving R1 and R2 alone together.
Continued 9099-C |
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32 | Resident interview revealed resident was upset the staff asked the resident to keep an eye on the resident while going in the other room and shutting the door. R1 is afraid of R2 and did not like being left alone like that. Staff interviews revealed Resident 3 (R3) needs 2 person assist with Hoyer lift so staff told the 2 residents that were in the room together that the staff were going into the other room to take care of R3 and would need to shut the door to R3’s room so if R1 & R2 needed anything the staff would be in R3’s room, Staff stated when staff said that staff did not mean R1 had to watch R2. Based on evidence this allegation is Substantiated at this time.
On the allegations: Staff do not provide accurate dosage of medication to resident. LPA reviewed R1’s Medication lists dated 05/18/2026 and 07/20/2026, Medication Administrator Record (MAR) dated July 2026, Centrally Stored Medication and Destruct Record (CSMDR) for 2026, PRN and One-Time Medication Records for June-July 2026, conducted an audit of pill counts for Quetiapine and Lorazepam medications for June and July 2026. The records and pill counts matched with correct count of medications as of 07/30/2026 when LPA audited the medications and records.
LPA reviewed R1’s medication records which revealed R1’s physician ordered medication Quetiapine 25mg was to be given 1 time a day at bedtime then on 07/20/2026 prescription was changed to 50mg to be given at 3pm for sundowning, may advance to100 mg daily after 2 weeks if continuing to have disruptive sundowning. The new medication was listed on the CSMDR and on the MAR according to the orders. The start dates of the old and new medication orders for each bottle were listed and the pill counts of medication at the facility matched the records. LPA reviewed records for Lorazepam Medications the new order from the doctor 07/20/2026 was 0.5mg tab PO BID PRN, to be given by mouth 2x per day as needed, based on the record review the facility never used over the prescribed PRN dosage.
LPA interviews with staff indicated the prescribed medication being given at 11:00am instead of the prescribed time of 3:00pm, the dosage given was 25mg as the staff was using up the remainder of the previous order for 25mg tablets before starting the 50 mg tablets, and felt another 25mg could be given at 3pm if needed, as it would still not go over the 50mg currently prescribed, the new ordered was ordered on 07/20/2026, it was filled by the pharmacy and was written on the CSMDR with a start date of 07/29/2026, the MAR indicates 2x 25mg tablets were given on 27th and the 28th finishing the old bottle and starting the new bottle on the 07/29/2026. LPA interviews with Witnesses felt R1 was out of it and not normal self on a visit to see R1 later in the morning on 07/23/2026. Records review do not show the staff gave R1 more than the prescribed dosages of medications. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/11/2026
Section Cited
CCR
87465(e) | 1
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7 | (e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank,...This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to train all staff on regulation 87465 each residents medications, make sure the facility has signed dated and written orders for all residents medications by physicians, make sure all medication written on the (Cont. below) |
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14 | Based on interviews and record review the Licensee did not comply with the regulation above in S1 gave R1 medication Quetiapine at 11:00 am without a dated written order from R1’s physician for the okay to give the 3pm medication at 11:00am which possess a potential Health, Safety and Personal Rights risk to residents in care. | 8
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14 | CSMDR and MAR match the written orders and provide proof of training, staff signatures and an up-to-date LIC 500 to CCL. |
Type B
08/11/2026
Section Cited
CCR
87464(f)(1) | 1
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7 | (f)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to train all staff in regulation 87464 and facility policy and procedures for care and supervision of each resident in care and follow the resident’s appraisal needs and services plans. Provide additional supervising R1 when the regular staff are busy. |
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14 | Based on interviews the Licensee did not comply with the regulation above, staff left R1 & R2 alone together in one resident’s room while tending to R3 when R2’s needs require staff supervision which possess a potential Health, Safety and Personal Rights risk to residents in care. | 8
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