Complaint·April 9, 2025

A review of R3’s prescribed medication revealed two routine medications for April 10th and 11th of 2025 were no longer present in the prescription bubble pack issued by the pharmacy. During their interview, S1 stated they were aware the medication for the two days was missing, but stated they were unsure of how the discrepancy occurred. Three additional staff interviewed denied any knowledge of the missing medication. A review of R4’s prescribed medication indicated two routine medications for April 10th and 11th of 2025 were no longer present in the prescribed bubble pack issued by the pharmacy. During their interview, S1 stated they were aware the medication for the two days was missing, but stated they were unsure of how the discrepancy occurred. Three additional staff interviewed denied any knowledge of the missing medication. A review of R5’s medication indicated three routine medications were not administered on March 30th, 2025, as they were still present in the prescription bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had not been signed by staff to indicate why it had not been administered or otherwise. A review of R6’s medication indicated one routine medication was not administered on March 23rd, 24th, and 29th of 2025, as it was still present in the prescribed bubble pack issued by the pharmacy. Upon review of MAR, it was observed it had been signed by staff to indicate it had been administered despite it still being present in the prescription bubble pack. Regarding allegation Staff did not ensure resident records were properly managed, the following was reviewed: Upon review of MARs for select residents, LPA observed discrepancies in four of nine resident records. Upon review of R1’s MAR, it was observed it had not been signed by staff on March 29th, 30th, and 31st of 2025 to indicate why six routine medications had not been administered or otherwise. Upon review of R2’s MAR, it was observed it had not been signed by staff on March 29th, 2025 to indicate why one routine had not been administered or otherwise. Upon review of R5’s MAR, it was observed it had not been signed by staff on March 30th, 2025 to indicate why three routine had not been administered or otherwise. Upon review of R6’s MAR, it was observed one routine medication had been signed by staff on March 23rd, 24th, and 29th of 2025 to indicate it had been administered despite it still being present in the prescription bubble pack. Regarding allegation Staff did not ensure reporting requirements were followed: LPA conducted a record review of Incident Reports (LIC624) submitted by the facility to Community Care Licensing (CCL) and did not observe any incidents reports for the medication errors listed above. During today’s visit, LPA was provided with an incident report for medication errors. (Cont. LIC9099-C) Based on staff interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.