complaint·June 17, 2025

Allegation: Staff are mismanaging resident's medication. The complaint alleges that resident (R1) did not receive blood pressure medications Furosemide 20 mg or Hydrochlorothiazide 25 mg for three days, and when med-techs were asked about the non-filled medications they had no idea why the medications were not filled. Resident (R1) stated in the past staff have given the resident another resident's medications, but the error was caught by the resident. A total of 15 residents were interviewed, of which 2 residents stated they have not been administered medications as directed by their physician. A total of nine staff were interviewed. Med-tech and Administration staff acknowledged that on June 14, 2025, resident (R1) ran out of the two aforementioned medications but did not contact R1's doctor or pharmacy until Saturday June 15, 2025. LPA called the facility pharmacy and R1's Primary Care Physician's office. The findings indicate that med-tech staff contacted the pharmacy and doctor until after the resident ran out of the medications. Based on record review of Medication Administration Records, med-tech staff did not communicate to Wellness Director or Executive Director that the pharmacy did not have a physician order for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg. The pharmacist stated that on Sat. June 14, 2025 they delivered an emergency 3-day supply of medications. However, the QuickMar MAR states the medications were not dispensed, and notes indicate the medications are still pending. In addition, the pharmacy sent all the routine medications to the facility on June 11, 2025, with the exception of the two medications. Staff did not observe the two medications were not delivered. Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were provided.