Complaint·August 18, 2025

(Continuation from LIC9099) Information received by the pharmacy further corroborated that staff did not place the initial order to fill prior to the medication running out on 3/18/2024. An order to fill was received on 3/20/2024 and medication was refilled/delivered on 3/21/2024. Therefore, the order delay resulted in medication being inaccessible to R2 if and when it was needed. It was further alleged that staff is mismanaging residents’ medication. Through record review, the MAR divulged R2’s medication was “not in cart” on 3/18/2024. Interviews confirmed when staff document that medication is “not in cart”, it means resident finished the medication and a new order is needing to be placed. On the afternoon of 3/19/2024, S1 documented R2 refused the medication. On the morning of 3/20/2024, Staff #2 (S2) documented on the MAR that the medication was “not in cart will follow up”. The afternoon of 3/20/2024, S1 documented on the MAR that R2 was administered the medication. Verbal information received by the pharmacy confirmed that the medication order was placed on 3/20/2024 and filled on 3/21/2024. The previous order for that medication was placed in February of 2024. Therefore, the facility staff did not have medication to offer or provide to R2 as it was previously alleged by S1 on the listed dates. Based on interviews and records review, the allegations of staff do not ensure resident is administered medications as prescribed, and staff is mismanaging resident's medications has been determined to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations (Title 22, Division 6 & Chapter 3) are being cited on the attached LIC 9099D). An exit interview was conducted and a copy of this report, 9099D, appeal rights, and LIC811-confidential names list were reviewed and provided to Administrator, Mollie Bowie. (Continuation from LIC9099A) The facility does not retain records of residents enlisting and/or changing their pharmacy as it is the decision of the resident and the resident’s responsible party. Per Mollie, the resident and their responsible party are the only people allowed to enroll and/or make changes to the residents pharmacy. If a resident chose to enroll in Market Pharmacy, the resident would have to contact Market Pharmacy directly to enroll. A review of R1’s file was conducted, and it did not contain any documents related to which pharmacy R1 is utilizing. Additional interviews conducted with a relevant party, corroborated that R1 is the only person able to change the pharmacy and changes can be conducted over the phone Based on interviews and records review, the allegation of staff changed resident's pharmacy without resident's consent is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator, Mollie Bowie.