complaint·January 22, 2025

The allegation revealed the following: Allegation: Facility staff did not assist resident with obtaining medication refill as needed It is being reported that staff allowed the resident ran out of her medications without ensuring she had a refill or assist her with obtaining a refill. On January 22, 2025, LPA Lee reviewed Nursing Notes(dated 12/30/24 at 10:00am) which revealed that S1 made several calls to in an attempt to ensure that R1 receive her refills. According to the note, communication to Pharmacy representative was made in addition to R1's doctor, and the responsible party. On January 22, 2025 LPA Lee interviewed R1-R5, and of those interviewed 4 of 5 state that the staff always help them obtain refills to their medication. Additionally, 4 out 5 stated that they have never ran out of medication. On January 22, 2025 LPA Lee interviewed staff 1-3 (S1-S3) and administrator (A1). Of those interviewed 3 out of 3 staff and Administrator stated that facility staff always assist residents in obtaining a refill of medication when needed. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of "Facility staff did not assist resident with obtaining medication refill as needed" found to be UNSUBSTANTIATED. N o deficiencies cited during today's visit. An exit interview was conducted, and a copy of report was give to Peggy Clark Administrator. The investigation revealed the following: Allegation: Facility staff did not dispense medications to resident as prescribed On January 22, 2025, LPA Lee conducted a review of R1 service file including Medication Administration Record (MAR). Records revealed that R1’s cycle of medication was missed on the following dates: 12/30/24, 12/31/24, 1/1, 1/2/25, 1/3/25, 1/4/25, 1/5/25, and 1/6/25. LPA Lee interviewed S1-S3 and Administrator (A1). 3 out 3 staff and administrator state that medication is dispensed as prescribed and on time, however, R1 changed her insurance and doctor who sent prescription to an outside pharmacy which delay process of them getting the medication on time. LPA interviewed Residents 1-5 (R-1 thru R-5). Of those interviewed, 4 out of 5 they receive their medication as prescribed and on time. According to the information gathered there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.) Deficiencies are issued and an exit interview is conducted with Peggy Clark. A copy of this report and appeal rights were provided.