complaint·November 14, 2024

Allegation: Staff did not reorder medications timely causing residents to miss medication. On 09/11/2024 the Department audited the facilities Medication Administration Records (MAR) dated September 2024. The facility uses an electronic Mar (eMar). Documents were reviewed for 4 residents, and 4 out of 4 eMAR’s showed blank spaces throughout the record. Per the charting codes given on the eMar, there is a code for each action, so there should be no blanks spaces for daily medications. On 08/14/2024 and 09/11/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have any residents run out of medications? Of those interviewed 1 out of 6 staff interviewed stated that they knew of only one resident who ran out of medicine since they have been working there. On 09/11/2024 LPA interviewed residents #1-#4 (R1-R4). Of those interviewed 4 out of 4 residents confirmed that medication was intermittently distributed to them because of a change in staff. Additionally, LPA interviewed resident 1 – 4, and asked them who reordered their medications. Of those interviewed 2 out of 4 stated their doctors reordered their medications, one out 4 stated that a family member reorders their medications, and one stated that the med-tech reorders their medications. An Interview with the administrator Sabina Nayberg revealed that one of the residents ran out of medication. The administrator stated that the residents’ doctor was called twice to refill depleted medication but did not respond. The resident whose medication had ran out, received their missing medication later. CONTINUED ON 9099-C Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED. California code of regulations title 22, division 6, chapter 8 are being cited on the attached LIC 9099D. An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to the Director of Operations Emmanuel Ruiz.