complaint·March 7, 2024

Allegation : Facility staff mismanaged residents' medications. It is alleged that residents have missed medications and that some have not had their prescriptions filled. On 12/14/2023 LPA Shirley reviewed facility records. LPA received copy of eMAR for resident 1 – resident 4 (R1-R4). LPA Shirley noted that most R1, R2 and R3 missed several days of medications. LPA requested and received incident reports from the last 6 months. Upon record review, LPA did not observe any report notifying CCLD of the pharmacy switch and issues dispensing medications. On 12/14/2023 LPA Shirley spoke to facility Administrator Ernest Lewis regarding the allegations. During interview administrator stated facility implemented a new system for dispensing medications as the facility had a change in pharmacy. Administrator further stated that several of the med techs could not access the new program, so there was a manual medication log being used. LPA Shirley requested copies of the facilities manual log. On 12/19/2023 LPA Shirley called to follow-up on the manual mediation logs and was told by Administrator Ernest Lewis that he could not obtain logs. As of 3/7/2024, no copies of the manual logs have been provided. LPA interviewed Staff 1 to Staff 6 (S1-S6). LPA asked staff if there is a history of missed medications at the facility. Of those interviewed, 4 out of 6 indicated there is no history. LPA interviewed resident 1 to resident 9, (R1 to R9), R10 was not available. LPA ask residents, “Have you ever missed getting your medication?” Of those interviewed, 5 out of 9 had no issues. Con'd on 9099-C Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 9099-D. An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Director Ernest (EJ) Lewis whose signature on this form confirms receipt of these documents.