complaint·August 8, 2025

On 08/01/25, Executive Director emailed August 2025 Activity Calendar and medication discontinuation and refill rosters for five residents. On 08/08/25, LPA conducted four (4) staff (S9 – S12) interviews and obtained identification and emergency information and needs and services plans for five memory care residents. LPA toured the common areas of the facility. Investigation revealed the following Allegation: Staff did not provide resident medication as prescribed Record review of the facility’s Plan of Operation indicated that "medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1) The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication, unless medication is on a cycle refill with the pharmacy…. 2) If necessary, the prescribing physician is contacted for a new order. 3) Medications are never allowed to run out unless directed to by the physician (obtain this direction in writing). Record review of R1’s February 2025 Medication Administration Record (MAR) revealed that medication A was out of stock as of 02/20/25, medication B as of 02/22/25, medication C and D as of 2/23/25, and medication E and F as of 02/26/25. Record review of R1’s refill order did not provide a refill date request for medication A and B. Medication C, D, and E refills were requested on 02/21/25. Medication F refills was requested on 02/26/25. Record review of R4’s July 2025 MAR revealed medication A was missed on 7/2, 7/6, 7/8, 7/10, 7/12, and was requested to be refilled on 07/17/25. Medication B was missed on 7/4, 7/6, 7/10 and requested to be refilled on 7/17/25. Record review of R5’s July 2025 MAR revealed medication A was unavailable from 07/09/25 – 07/13/25 and the request for refill was submitted 07/16/25. Medication B was missed 07/03/25, 07/09-07/10, 07/12-07/13 AM and 07/07, 07/09 - 07/12 PM and was requested to be refilled on 07/16/25. Medication C was missed on 7/2 - 7/3, 7/6 - 7/7, 7/9 - 7/12. Record review of R12’s March 2025 MAR revealed R12’s medication A – G was out of stock as of 03/19/2025. Record review of R14’s May 2025 MAR revealed medication A was missed on 5/1 - 5/4, 5/6 - 5/11, 5/13, 5/15 - 5/19, 5/21 - 5/24, 5/29 - 5/31 and medication B was missed on 5/1, 5/5-5/7, 5/10, 5/13, 5/17-5/19, and 5/24. Regarding the allegation, “Staff did not provide resident medication as prescribed” based on record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC 9099D. An exit interview was conducted, plans of correction developed, and a copy of this report with appeals was provided to the Wellness Director Michelle Brown.