complaint·August 28, 2025

The investigation revealed the following: Regarding: Staff are mismanaging resident's medications. It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE. QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the PRN Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates. Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their PRN Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation. Based on record review and staff and resident interviews , the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and the resident's response for May 2, 4 and 5, 2025 for R1. The preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.