Inspection Reports for
Lexington Assisted Living

The complaint investigation was substantiated. The allegation involved neglect and lack of care and supervision due to failure to dispense prescribed medication, causing serious bodily injury to Resident #1.

The Department found that the facility failed to administer prescribed medication to Resident #1, resulting in a seizure requiring medical attention and hospitalization. The licensee was cited for violation of California Code of Regulations 87465(a)(4) and assessed civil penalties totaling $10,000, with $9,500 issued on this visit due to a prior penalty.

The complaint investigation was substantiated for neglect/lack of care and supervision. The licensee was cited and fined civil penalties totaling $10,000, with $500 issued immediately on January 21, 2025, and an additional $9,500 issued on August 21, 2025, for serious bodily injury.

The Department found that staff failed to administer prescribed medication to Resident #1, resulting in a seizure requiring medical attention and hospitalization. The licensee was cited for violation of California Code of Regulations 87465(a)(4) and was subject to civil penalties.

The inspection found that the centrally stored medication and destruction record was missing start dates on nearly all medications for Resident 1. Medications were not properly documented or administered as prescribed, posing an immediate health and safety risk. An immediate civil penalty of $1,000 was assessed for a repeat violation.

The Clinical Director and Licensing Program Analyst found that the centrally stored medication and destruction record was missing start dates on nearly all medications for Resident 1, and medication administration records showed discrepancies with pills remaining despite documentation of administration, posing an immediate health and safety risk.

The visit was a follow-up to a substantiated complaint investigation (complaint control number 29-AS-20210226132843) regarding Resident #1 sustaining multiple fractures while in care. The complaint was substantiated and resulted in citations and civil penalties.

The Department determined that a civil penalty is warranted for serious bodily injury due to the facility's failure to provide proper care and supervision, resulting in multiple fractures from multiple falls. A civil penalty of $9,500 was issued after accounting for a prior $500 penalty.

The visit followed a substantiated complaint investigation (complaint control number 29-AS-20210226132843) regarding Resident #1 sustaining multiple fractures while in care. The licensee was cited and previously issued an immediate civil penalty of $500 on February 24, 2022. The Department concluded that a civil penalty for serious bodily injury is warranted.

The Department determined that a civil penalty is warranted for serious bodily injury due to the facility's failure to provide proper care and supervision, resulting in multiple fractures from multiple falls. A civil penalty of $9,500 was issued following a prior immediate penalty of $500.

The visit was conducted in conjunction with a complaint investigation (Complaint Control # 29-AS-20240829092756).

Deficiencies were found related to medication management where a resident (R1) did not receive a prescribed seizure medication for 10 days, resulting in a seizure and hospitalization. Additionally, R1's Physician Report was incomplete due to a missing physician's signature.

The complaint alleged neglect/lack of care and supervision due to failure to dispense prescribed seizure medication to Resident #1, resulting in medical attention. The allegation was substantiated. Another complaint alleging questionable death due to multiple seizures and neglect was unsubstantiated. The allegation that the resident's room was left unkempt was also unsubstantiated.

The investigation substantiated that the facility failed to administer one of the two prescribed seizure medications to Resident #1, which resulted in a seizure requiring medical attention and posed an immediate health and safety risk. A $1,000 immediate civil penalty was assessed due to a repeat violation. The allegation that R1's room was left unkempt was unsubstantiated, and the allegation that R1 sustained multiple seizures and subsequently expired due to staff neglect was also unsubstantiated.

The complaint was substantiated regarding neglect/lack of care and supervision due to failure to dispense prescribed seizure medication to Resident #1, causing a seizure and medical attention. The allegation of questionable death due to staff neglect was unsubstantiated. The allegation that the resident's room was left unkempt was also unsubstantiated.

The investigation substantiated that staff failed to administer one of R1's prescribed seizure medications, leading to a seizure and medical attention, resulting in a $1,000 immediate civil penalty for repeat violation. The allegation that R1 sustained multiple seizures and subsequently expired due to staff neglect was unsubstantiated. The allegation that R1's room was left unkempt was also unsubstantiated based on observations and staff interviews.

The complaint investigation was initiated due to allegations of lack of supervision resulting in injury and failure to notify the resident's responsible party of an incident. The lack of supervision allegation was unsubstantiated, while the failure to notify allegation was substantiated.

The allegation of lack of supervision resulting in injury was found to be unsubstantiated due to insufficient evidence. However, the allegation that the facility failed to notify the resident's responsible party of an incident was substantiated, citing non-compliance with reporting requirements.

The complaint investigation was triggered by allegations that the facility did not provide adequate supervision resulting in injury to Resident 1 (R1), and that the facility failed to notify the resident's responsible party of the incident. The lack of supervision allegation was unsubstantiated, but the failure to notify allegation was substantiated.

The allegation of lack of supervision resulting in injury was found to be unsubstantiated due to insufficient evidence. However, the allegation that the facility failed to notify the resident's responsible party of the incident was substantiated, citing a violation of California Code of Regulations requiring notification within seven days.

The facility was generally in good condition with no health or safety hazards noted in physical plant areas. However, two deficiencies were cited: missing medication dose start dates in centrally stored medication records, and hot water temperature exceeding regulatory limits in one resident bathroom. Plans of correction were submitted with due dates.

The facility was generally in compliance with health and safety regulations, including kitchen safety, common area conditions, and emergency preparedness. However, two deficiencies were cited: missing medication dose start dates in centrally stored medication records and hot water temperature exceeding regulatory limits in one resident bathroom.

The visit was triggered by a complaint investigation (complaint control number 29-AS-20240829092756). The complaint was substantiated as deficiencies were found related to failure to report incidents as required.

The facility failed to submit required incident and death reports to Community Care Licensing for a resident's medical emergency on 8/13/2024 and subsequent death on 8/20/2024, posing potential health, safety, or personal rights risks to residents.

The visit was triggered by a complaint investigation (complaint control number 29-AS-20240829092756). The complaint involved a resident who had a medical emergency on or about 8/13/2024 and subsequently passed away on or about 8/20/2024. The facility did not report the incident or death to the licensing agency as required.

The facility failed to submit required incident and death reports to the licensing agency within the mandated timeframe, posing potential health, safety, or personal rights risks to residents in care.

The complaint included allegations of staff inappropriately handling a resident, not answering call lights timely, speaking inappropriately to a resident, inability to communicate with a resident, inadequate food quantity and quality, failure to assist with medication self-administration, and failure to provide shower assistance. The investigation determined most allegations were unsubstantiated except for failure to assist with medications and showering, which were substantiated.

The investigation found insufficient evidence to substantiate most allegations including inappropriate handling of a resident, untimely response to call lights, inappropriate speech by staff, communication barriers, and inadequate food quantity and quality. However, two allegations were substantiated: staff did not assist a resident with self-administration of medications as prescribed during the first days after move-in, and staff did not provide shower assistance as required during the first week of residency.

The complaint investigation was triggered by allegations including inappropriate handling of a resident, untimely response to call lights, inappropriate speech by staff, communication issues, inadequate food, failure to assist with medication administration, and failure to provide shower assistance. Most allegations were unsubstantiated except for failure to assist with medications and showering, which were substantiated.

The investigation found insufficient evidence to substantiate most allegations including inappropriate handling of a resident, untimely call light responses, inappropriate speech by staff, communication barriers, and inadequate food quantity and quality. However, two allegations were substantiated: staff did not assist a resident with self-administration of medications as prescribed during the first days after move-in, and staff did not provide shower assistance as required during the resident's first week at the facility.

The visit was conducted in conjunction with complaint visit CC #29-AS-20231020083938. The deficiencies cited were observed during the complaint investigation but were not related to the complaint itself.

The facility was unable to provide all of Resident #1's medication records, as they archived all records and marked medications as discontinued when residents move out or expire, posing a potential health and safety risk to residents in care. A citation was issued.

The complaint was received on 2023-10-20 alleging neglect and lack of care and supervision, including failure to provide medication to Resident #1 which allegedly contributed to death, failure to ensure a resident's pendant was functioning, and failure to communicate with an authorized representative. The investigation included interviews with staff, residents, resident representatives, medical providers, and review of medical and facility records. The allegation of medication failure and delayed response to assistance requests were substantiated; other allegations were unsubstantiated.

The investigation found insufficient evidence to substantiate allegations regarding failure to ensure the pendant was functioning and failure to communicate effectively with the authorized representative. However, the allegations that facility staff failed to provide medication to Resident #1 and failed to attend to R1's request for assistance in a timely manner were substantiated. Deficiencies were cited related to medication administration and staffing levels, posing immediate health and safety risks.

The visit was conducted in conjunction with complaint investigation CC #29-AS-20231020083938. Deficiencies cited were not related to the complaint but were observed during the investigation. The facility was unable to provide all medication records for Resident #1, posing a potential health and safety risk.

The facility was unable to provide all of Resident #1’s medication records, as they archived all records and marked medications as discontinued when residents move out or expire. This posed a potential health and safety risk to residents in care. A citation was issued.

The complaint was received on 10/20/2023 alleging neglect and lack of care and supervision, including failure to provide medication to Resident #1 (R1) which allegedly contributed to R1's death, failure to attend to R1's requests timely, malfunctioning pendants, and ineffective communication with authorized representatives. The investigation concluded the medication and pendant allegations related to death and pendant malfunction were unsubstantiated, but the failure to provide prescribed medications and timely response to assistance requests were substantiated.

The investigation found insufficient evidence to substantiate allegations related to failure to provide medication contributing to R1's death, malfunctioning pendants, and ineffective communication with authorized representatives. However, the allegations that facility staff failed to provide certain prescribed medications (Buprenorphine, Ticagrelor, Aspirin) to R1 and failed to respond to R1's requests for assistance in a timely manner were substantiated. Deficiencies were cited related to medication administration and staffing levels impacting resident care.

The facility was generally found to be in compliance with health and safety regulations, including kitchen safety, common area conditions, and proper record keeping. One deficiency was noted regarding a mismatch in the prescription number on a resident's medication bottle compared to the centrally stored medication record, which was corrected during the visit.

The facility was generally found to be in compliance with health, safety, and regulatory requirements including physical plant conditions, kitchen safety, resident bedrooms, restrooms, and records. One deficiency was cited related to a medication record discrepancy involving a mismatched prescription number, which was corrected during the visit.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Esther Cortez. Allegations included failure to provide adequate food service, failure to meet resident's medical needs, and failure to meet resident's hygiene needs. The food service and medical needs allegations were unsubstantiated, while the hygiene needs allegation was substantiated.

The investigation found insufficient evidence to substantiate allegations regarding inadequate food service and unmet medical needs. However, the allegation that staff failed to meet a resident's hygiene needs was substantiated due to false documentation of showering and lack of records verifying showers for the resident over a specified period.

The complaint investigation was triggered by allegations that staff failed to provide adequate food service, failed to meet resident's medical needs, and failed to meet resident's hygiene needs. The food service and medical needs allegations were unsubstantiated. The hygiene needs allegation was substantiated due to evidence of inadequate bathing and false documentation by staff.

The investigation found insufficient evidence to substantiate allegations regarding inadequate food service and unmet medical needs, deeming those allegations unsubstantiated. However, the allegation that staff failed to meet resident's hygiene needs was substantiated due to lack of proper shower documentation and false recording by staff, posing a potential health and safety risk.

The visit was complaint-related due to two elopement incidents: Resident #1 eloped on 07/20/2023 and Resident #2 eloped on 07/31/2023. Resident #1 does not have dementia and can leave unassisted per physician report, but staff had concerns about safety. Resident #2 has dementia and cannot leave unassisted. The complaint was substantiated with deficiencies cited.

The investigation found that Resident #1's change in condition was not documented or reported to the primary care physician, and Resident #2, diagnosed with dementia, left the facility unassisted due to insufficient staffing and front desk staff being on break. Deficiencies were cited related to inadequate staffing and failure to update resident reappraisals.

The visit was complaint-related, triggered by two Unusual/Serious Incident Reports (SIRs) regarding residents eloping from the facility. Resident #1 eloped on 07/20/2023 and Resident #2 eloped on 07/31/2023. Resident #2's elopement was substantiated due to insufficient staffing and lack of monitoring.

The investigation found that Resident #1 eloped but does not have dementia and is allowed to leave unassisted, though staff had concerns about their safety. Resident #2, diagnosed with dementia and unable to leave unassisted, also eloped due to insufficient staffing and lack of monitoring. Deficiencies were cited for inadequate staffing and failure to update resident reappraisals and notify physicians of condition changes.

The complaint investigation was triggered by allegations including residents being left sitting in chairs all day, inadequate care and supervision, failure to safeguard personal items, residents not dressed in their own clothing, multiple falls sustained by a resident, failure to follow reporting requirements, and a scabies outbreak. The allegations regarding care, supervision, safeguarding personal items, and clothing were unsubstantiated. The allegations regarding multiple falls, failure to report incidents timely, and scabies outbreak were substantiated.

The investigation found the allegations that residents were left sitting in a chair all day, staff did not provide adequate care and supervision, staff did not safeguard residents' personal items, and residents were not dressed in their own clothing to be unsubstantiated. However, allegations that a resident sustained multiple falls, the facility did not follow reporting requirements, and the facility had scabies were substantiated.

The complaint investigation was triggered by allegations received on 05/21/2021 concerning resident neglect, inadequate supervision, loss of personal items, improper clothing, multiple falls, failure to report incidents, and a scabies outbreak. The investigation was conducted through interviews, record reviews, and facility tours. The allegations regarding neglect, supervision, personal items, and clothing were unsubstantiated, while those regarding multiple falls, scabies, and reporting failures were substantiated.

The investigation found the allegations that residents were left sitting all day, staff did not provide adequate care and supervision, staff did not safeguard personal items, and residents were not dressed in their own clothing to be unsubstantiated. However, the allegations that a resident sustained multiple falls, the facility had scabies, and the facility failed to follow reporting requirements were substantiated. Deficiencies were cited related to personal rights and reporting requirements.

The complaint investigation was substantiated regarding staff not following physician's orders for residents R1 and R2, including failure to change R1's fentanyl patch every 72 hours and failure to administer R2's routine Morphine and Lorazepam every four hours. The allegation that staff did not answer residents' call lights timely was unsubstantiated.

The investigation substantiated that staff failed to follow physician's orders regarding medication administration for two residents, R1 and R2, posing an immediate health and safety risk. However, the allegation that staff did not answer residents' call lights timely was unsubstantiated due to insufficient evidence.

The complaint alleged that staff were not following physician's orders for residents R1 and R2, specifically regarding timely administration of fentanyl patches and routine Morphine and Lorazepam medications. It also alleged staff did not answer residents' call lights timely. The fentanyl patch administration was not consistently done every 72 hours as prescribed, and medication administration records did not align. Staff failed to wake R2 to administer routine medications at prescribed times. The call light response allegation was found unsubstantiated.

The investigation substantiated that staff failed to follow physician's orders regarding medication administration for two residents, posing an immediate health and safety risk. However, the allegation that staff did not answer residents' call lights timely was unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for allegations that resident #1 was left soiled for a long period, did not have access to personal possessions, and was not provided meals. Allegations that the resident's call button was inoperable and that medication was not given timely were unsubstantiated.

The investigation substantiated that a resident was left soiled for a long period, did not have access to personal possessions (hearing aids), and staff did not provide meals to the resident. Two other allegations regarding inoperable call button and untimely medication administration were unsubstantiated.

The inspection found that resident R1 did not receive their prescribed Escitalopram 5 mg tablets on 2/17/22, 2/18/22, and 2/19/22 due to lack of medication refill, posing an immediate health risk. A deficiency was cited for failure to assist residents with self-administered medications as required.

The licensee failed to administer prescribed medication (Escitalopram 5 mg) to resident R1 on three consecutive days due to lack of medication supply, posing an immediate health risk.

Complaint investigation was substantiated for allegations that resident #1 was left soiled for a long period, did not have access to personal possessions, and was not provided meals on 2/19/22. Allegations regarding inoperable call button and untimely medication were unsubstantiated.

The investigation substantiated that resident #1 was left soiled for a long period, did not have access to personal possessions (hearing aids), and staff did not provide meals to the resident on 2/19/22. Allegations that the resident's call button was inoperable and that medication was not provided timely were unsubstantiated.

The complaint was substantiated regarding rough handling of residents causing extreme pain during care. The allegation of inappropriate speech by staff was unsubstantiated.

The investigation substantiated that facility staff handled residents roughly causing extreme pain during assistance with toileting and transferring, posing an immediate health and safety risk. The allegation that staff spoke inappropriately to residents was unsubstantiated.

The inspection found that disinfectants and toxic substances were accessible to residents in an unlocked beauty parlor, violating Title 22 Division 6 Chapter 8 of the California Code of Regulations. A civil penalty of $250 was issued.

A deficiency was cited for storing disinfectants and toxic substances accessible to residents with dementia, posing an immediate health risk. A civil penalty of $250 was issued.

The complaint was substantiated regarding rough handling of residents causing extreme pain during toileting and transferring, but unsubstantiated regarding inappropriate speech by staff to residents.

The investigation substantiated that facility staff handled residents roughly while assisting with toileting and transferring, causing extreme pain but no injuries. The allegation that staff spoke inappropriately to residents was unsubstantiated.

The complaint was substantiated. The allegation involved resident #1 inappropriately touching female residents and making verbal advances. Interviews and observations confirmed these behaviors. Resident #1 denied the allegations during interview. Resident #2 could not be interviewed due to diagnosis. The licensee was found non-compliant with regulations protecting residents' personal rights.

The investigation substantiated that resident #1 engaged in inappropriate physical and verbal behavior towards other residents, violating their personal rights. Staff interviews and observations confirmed these behaviors, and the facility was cited for failing to protect residents from neglect and abuse.

The visit was complaint-related to an alleged incident involving residents #1 and #2 reported on 08/05/2022. The deficiency was substantiated by observations of toxic items accessible to residents.

During the visit, toxic substances including paint, painter's acrylic latex caulk, fragrance mist, and body lotion were observed accessible to residents, violating Title 22 Division 6 Chapter 8 of the California Code of Regulations. A deficiency was cited and a civil penalty of $250 was issued.

The visit was complaint-related, investigating an alleged incident involving residents #1 and #2 reported on 08/05/2022. The deficiency cited was substantiated by observations during the visit.

During the visit, toxic items such as paint, painter's acrylic latex caulk, fragrance mist, and body lotion were observed accessible to residents, which poses an immediate health risk. A deficiency was cited under Title 22 Division 6 Chapter 8 of the CA Code of Regulations, and a civil penalty of $250 was issued.

The complaint was substantiated. Allegations involved resident #1 inappropriately touching female residents and making verbal advances. Interviews and record reviews supported these findings. Resident #1 denied the behaviors, and resident #2 could not be interviewed due to diagnosis.

The investigation substantiated the allegation that resident #1 was inappropriately touching female residents and speaking inappropriately to them, posing an immediate safety and personal rights risk. Staff interviews and record reviews confirmed these behaviors, and the facility was cited for failing to protect residents' rights.

The visit was triggered by complaint control #29-AS-20220726081704. The deficiency was substantiated with a zero-tolerance violation and a civil penalty was issued.

The inspection found that the gate leading to the facility's in-ground swimming pool was unlocked, posing an immediate health and safety risk to persons in care. A zero-tolerance violation was cited and a civil penalty of $500 was issued.

The visit was triggered by complaint control #29-AS-20220726081704. The deficiency was substantiated as the unlocked pool gate was observed during the investigation.

The inspection found that the door to the facility's in-ground pool was unlocked, posing an immediate health and safety risk to persons in care. Civil penalties of $500 were issued for this zero-tolerance violation.

The complaint was substantiated based on interviews and record reviews showing residents waited over 30 minutes for help and were not changed timely, including documented calls to 911 by residents for assistance.

The investigation substantiated the allegation that residents were not being changed timely, posing a potential health and personal rights risk. Multiple interviews and record reviews confirmed delays in care and assistance to residents.

The complaint was substantiated based on interviews and observations that residents were missing medications due to staff distraction and failure to administer medications as prescribed.

The investigation found that residents were indeed not administered their medications as prescribed, with staff admitting to being distracted and forgetting to give medications. Residents had to notify staff about missing medications. The allegation was substantiated.

Two Type A deficiencies were cited: accessible dishwashing liquid in the memory care laundry room posing an immediate health risk, and employment of a staff member without prior criminal record clearance association, posing an immediate safety risk. Civil penalties totaling $3,250 were issued.

Two Type A deficiencies were cited: one for storing dishwashing liquid accessible to residents with dementia, posing an immediate health risk, and another for allowing a staff member to work without proper criminal record clearance, posing an immediate safety risk. Civil penalties totaling $3,250 were issued.

The complaint was substantiated based on interviews and record reviews showing residents were not changed timely, with documented calls for help and caregiver notes indicating neglect in care.

The investigation substantiated the allegation that residents were not being changed timely, posing a potential health and personal rights risk. Interviews and record reviews confirmed delays in care and multiple calls for help by residents.

The complaint was substantiated based on interviews and observations that residents were missing medications when staff administered them, and staff admitted to distraction and omission.

The investigation found that residents were indeed not administered their medications as prescribed, with staff admitting to being distracted and forgetting to give medications. The allegation was substantiated.

The Licensing Program Manager discussed substantiated complaints and citations from the past three years and the Administrator's plans to maintain compliance. The Operations Manager described staffing status and new safety measures including delegated reporting, room sweeps, and secured medication/hazardous item storage.

The complaint investigation revealed that Resident #1's Needs and Services Plan had not been updated to reflect changes in condition after multiple falls and cognitive decline, despite residency beginning on 03/01/2020 and a recent fall on 04/21/2021. Additionally, staff member S1 was working without proper clearance and association with the facility.

The inspection found multiple deficiencies including accessible hazardous items to residents, unassociated staff working without proper clearance, failure to update resident Needs and Services Plans reflecting changes in condition, and improper storage of medications and dangerous items posing immediate health and safety risks.

The complaint was substantiated. The licensee did not report COVID positive residents to Community Care Licensing and Ventura County Public Health from 2/4/22 to 2/16/22, posing a potential health and personal rights risk to persons in care.

The investigation found that the facility failed to report COVID-19 positive residents to Community Care Licensing and Ventura County Public Health between 2/4/22 and 2/16/22, substantiating the complaint. Documentation showed 19 residents were COVID positive during that period, but no notification was made as required.

The complaint was substantiated. The licensee did not report COVID positive residents to Community Care Licensing and Ventura County Public Health from 2/4/22 to 2/16/22 as required.

The investigation found that the facility failed to report 19 COVID-19 positive residents to Community Care Licensing and Ventura County Public Health between 2/4/22 and 2/16/22, substantiating the allegation and posing a potential health and personal rights risk to residents.

The complaint was substantiated. Resident #1 sustained multiple fractures including a broken nose, compression fractures of L1 and L3, and 5 broken ribs. The investigation included interviews, records review, and multiple visits. A $500 immediate civil penalty was assessed.

The allegation of neglect/lack of supervision resulting in Resident #1 sustaining multiple injuries, including fractures, was substantiated. The facility failed to provide adequate care and supervision, leading to multiple falls and injuries to the resident.

The complaint was substantiated. Resident #1 sustained multiple fractures including a broken nose, compression fractures of L1 and L3, and 5 broken ribs. Multiple falls were documented, some unwitnessed, and the facility failed to provide adequate supervision and care. A $500 immediate civil penalty was issued.

The allegation of neglect/lack of supervision resulting in multiple injuries to Resident #1 was substantiated. The facility failed to provide adequate care and supervision, which contributed to the resident sustaining multiple injuries including fractures and falls. A $500 immediate civil penalty was assessed.

The complaint investigation (#29-AS-20210226132843) revealed that Resident #1's Needs and Services Plan had not been updated to reflect changes in condition after multiple falls and cognitive decline, and that an unassociated staff member worked at the facility.

The inspection found multiple deficiencies including unsafe storage of hazardous items accessible to residents, unassociated staff working at the facility, and failure to update a resident's Needs and Services Plan to reflect changes in condition. Civil penalties were issued totaling $1,800.

The complaint was substantiated based on interviews and record reviews indicating that unqualified staff administered medication without current annual training.

The investigation substantiated that staff member S1 had not completed the required annual medication training, having last received training six years prior, which poses a potential health risk to residents.

The complaint was substantiated based on observations and interviews during the unannounced visit. The Operations Manager was unaware of the vehicle's maintenance issues. The allegation was deemed substantiated at the time of the investigation.

The investigation found that the facility vehicle's windshield wipers were cracked and had not been replaced in at least two years, the right front tire was balding, and the vehicle registration tags were expired. These conditions posed a potential safety and personal rights risk to residents.

The complaint was substantiated. The allegation was that unqualified staff were administering medication. The investigation confirmed that staff member S1 had not completed annual medication training as required.

The investigation found that staff member S1 had not completed the required annual medication training, having last received training six years prior, which substantiated the complaint. A deficiency was cited for failure to meet medication training requirements, posing a potential health risk to residents.

The complaint regarding the facility transportation vehicle being in disrepair was substantiated based on observations and interviews during the investigation.

The investigation found that the facility vehicle's windshield wipers were cracked and had not been replaced in at least two years, the right front tire was balding, and the vehicle registration tags were expired. These conditions posed a potential safety and personal rights risk to residents.