Complaint·September 12, 2022

resident is signed up for Pharmerica; physician’s assessment dated 12/31/2021 states that resident can’t store and/or administer medications; doctor’s orders dated 1/23/2022. Resident R2 missed the following medication: Losartan 50 mg daily from 8/2/2022 to 8/10/2022 – family member was contacted on 8/10/2022 and was able to bring a refill of 7 tablets and on 8/15/2022 facility was able to receive a refill for 3 tablets according with records and Centrally Stored Medication Records (CSMR); facility contacted pharmacy however wasn’t able to receive prescription; Elequilis missed from 4/23/2022 to 4/26/2022; and Amoldine missed from 5/22/2022 to 5/23/2022 – according with CSMRs and Medication Administration Records (MARs) with state that medications were not available. (see copy of records) Resident R3 physician’s assessment dated 8/25/2017 states that facility manages medication and orders from pharmacy – Pharmerica; resident R3 has missed the following medications due to medication “not available” (see copy of MARs): Omeprazole 20 ml once daily from 5/1/2022 to 5/5/2022 and 6/20/2022 to 6/30/2022, Omeprazole 40 ml once daily from 6/21/2022 to 7/13/2022 – records show that facility contacted pharmacy letting them know that “had run out of medication”, Amoldipane 2.5 mg once daily from 6/10/2022 to 6/14/2022 – records show fax to pharmacy stating “ran out of medication on 6/7/2022, Valsartan 160 mg once daily “not available” from 5/30/2022 to 6/14/2022. (see copy of records, LIC 811 confidential name list, LIC 9099-D). Administrator and staff S1 stated that they had knowledge of resident R1 missing medication on August 2022 and that it was due to Pharmerica waiting for a renew doctor’s order to refill; doctor had been contacted and submitted refill order to the wrong pharmacy. Facility didn’t learn that refill had been submitted to the wrong pharmacy until resident R1 had already missed 8 days of medication. In addition, facility didn’t not submit incident report for any of the missing medication for R1 and R3 as it is required by Title 22 Regulations # 87211 Reporting Requirements. R4 missed Calcium from 7/21/22 to 7/25/22 .(see case management datimg 9/12/2022) Based on observations, interviews and documentation reviewed, Department was able to prove that facility did not dispense medication as prescribed by doctor. Continued LIC 9099-C According with complaint allegation "Facility did not dispense medication as prescribed by doctor.” there were related observations made during visit. Based on LPA observations, file reviewed, and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.