complaint·August 27, 2025

The document review revealed that staff had faxed medications request to R1’s doctor on 5-13-25, 5-15-25 and 5-20-25. The Administrator reported on May 22 I went to the VA in Chico and picked up two missing medications. Review of the Medication Administration Record revealed the two medications were documented and administered to the resident at this time. Further document review revealed the resident went without several other medications for seven days and two medications were never recorded as received or given. Durning interviews staff reported a visit from the VA nurse on 5-21-25. After a review of the residents’ medications, the nurse reported that a medication was not listed by the doctor’s admission, standing orders. Documentation of doctors’ orders dated 5-9-25 did not have the missing resident medication listed as a standing order. On 5-21-25 the nurse stated the missing medication would be delivered by mail. Staff reported on 5-25-25 the nurse phoned to see if the resident had received his missing medication per the visit and conversation on 5-21-25. Staff had stated no they had not received the package. The nurse reported to staff I have record that the medication had been delivered on 5-23-25. Staff reported reviewing security film footage and discovered a package was delivered from UPS on 5-23-25. Staff reported the package was found in the medication room in a drawer on 5-25-25 after security film review. Staff stated when the package was delivered it had the residents name on it so the staff declined to open the package. Staff reported that the facility doesn't usually get medication from UPS and the staff that took the package didn't realize the package was medication. Document review revealed this medication was delivered 5-23-25 and discovered on 5-25-25. Record review of the Medication Administration Record revealed the medication was not recorded or administered to the resident. Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.