complaint·March 27, 2025

LPA interviewed the facility’s medication technician supervisor who reported there were issues in December 2024 with residents on controlled pain medications but denied that any of these medications have been stolen. LPA reviewed the facility’s MAR for December 2024 for the five residents on controlled pain medications and noted the MARs are incomplete and do not properly document the medications dispensed. Per the facility’s medication technician supervisor, the facility is using a new electronic MAR system which does not always record the information that is entered, but the facility’s as-needed medication logs are still handwritten and properly document medications dispensed. LPA inspected the controlled pain medications for the five residents, all of which were in bubble packs, and observed no errors. LPA reviewed the January 2025 as-needed medication logs for the three residents who take controlled pain medications on an as-needed basis and confirmed the logs matched the medications administered and that there were no missing or extra pills. The facility’s medication technician supervisor denied that residents were ever given smaller doses than prescribed, but revealed that in December 2024 one of these residents missed one or two doses and was offered an alternate medication (Tylenol) because the facility ran out of supply of the resident’s controlled pain medication. LPA reviewed this resident’s medication list and confirmed Tylenol is one of their prescribed medications. Per the facility’s medication technician supervisor, this resident requests and takes this controlled pain medication four times a day. LPA reviewed this resident’s as-needed medication logs and noted approximately six days in November and December 2024 when the resident missed at least one dose of their controlled pain medication. LPA also noted that these logs did not document the facility’s attempts to refill the medication, which dates and times the medication could not be provided as requested, and the reason the medication could not be provided as requested. LPA inspected the medications for an additional 10 residents and did not observe any additional medication issues. LPA interviewed two additional medication technicians and did not obtain additional information regarding the allegation. LPA interviewed the four residents on controlled pain medications who were present at the facility and did not obtain additional information regarding the allegation. The information obtained corroborated that the facility did not dispense one resident’s medications as prescribed by running out of one of supply and that the facility instead dispensed an approved alternate medication. 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. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.