complaint·June 18, 2025

It was alleged that facility staff are not dispensing medications as prescribed. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed PA and three staff and one staff admitted that Resident #1’s (R1) Fosfomycin, which is to be administered every three days to prevent urinary tract infections, was not given as prescribed, as there are still medications from the April 2025 shipment that remain, and the facility did not order a May 2025 supply. LPA inspected R1’s Fosfomycin and confirmed that five doses from the April 21, 2025, shipment, which should have been given to R1, are still present at the facility. LPA reviewed R1’s Medication Administration Records and noted that this medication is document as having been properly given to R1, which is incorrect. Facility staff were unable to provide an explanation as to why R1’s Fosfomycin was not given as prescribed or why it was documented as having been properly given, but stated the situation is being investigated. LPA inspected the Medication Administration Records for five additional residents and noted that Resident #2 (R2) did not receive any of their medications on May 1, 2025 due to lack of supply. Facility staff were unable to provide documentation of their attempts to follow up with R2’s doctor and pharmacy to ensure R2’s medications were delivered timely. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies 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 discussed with and provided to facility representative.