complaint·June 19, 2025

Allegation: Staff are mismanaging resident's medication. The complaint alleges the facility failed to obtain two physician orders for blood pressure medication Amlodipine 2.5 mg, and antibiotic Macrobid 100 mg. According to information obtained, resident (R1) ran out of Amlodipine 2.5 mg in early May 2025 and obtained the medication until May 30, 2025. Regarding the antibiotic medication, it is alleged that on May 29, 2025 resident (R1) had symptoms of a urinary tract infection, and staff contacted R1's responsible party and was told that an antibiotic medication would be obtained. Nine residents were interviewed. None reported medication administration issues. A total of four (4) staff were interviewed. Based on interviews conducted, the findings indicate that staff initially contacted R1's pharmacy on 5/11/25 about Amlodipine 2.5 mg refill, but failed to document any follow-up details on Medication Administration Records, and communicate with Administration staff or Health Services Director that staff were having trouble getting a physician order for the medication. In regards to the antibiotic medication staff interviews revealed that R1's responsible party was informed a urine sample order would be requested from the physician. On May 29, 2025, R1's responsible party visited the resident at approximately 5:00 PM, and was told by staff they had not had any communication with R1's doctor about urinalysis or possible antibiotic. On May 30, 2025, physician orders were obtained after R1's responsible party contacted palliative care doctor on their own. QuickMar charting notes do not have any documentation that physician orders were obtained and medications were filled and brought to the facility by R1's responsible party on May 30, 2025. Therefore, there is sufficient evidence to corroborate the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Health Services Director Leticia Garcia. A copy of the report and appeal rights was issued.