Complaint·May 20, 2021

LPA Michael Bilger arrived unannounced at facility at 2:55pm to open a complaint for the above allegations. LPA requested the following documents from R1: Copy of recent centrally storage medication list, copy of most recent 602, and most recent medication orders. LPA reviewed documents and interviewed Administrator as well as S1 and S2. R1 is currently in the hospital. According to Administrator, all medication with the exception of the prescribed psych meds for R1 was not transferred from one pharmacy to a new pharmacy resulting in medication, including Metformin (diabetic medication) not being given since 3/25/21. Administrator acknowledged the medication error of R1 not receiving medication upon speaking with R1s conservator on 5/19/21. Administrator further acknowledged that S1 and S2 were not giving the medication as prescribed. S1 and S2 further acknowledged that medications were not given since 3/25/21 during their interviews. Medication training for S1 and S2 is current. Based on the findings during this visit and through record review, there is a preponderance of evidence to conclude that R1 did not receive medication as prescribed since 3/25/21, therefore, this allegation is SUBSTANTIATED. Deficiencies were cited today under Title 22 regulations, Division 8. A copy of this report and appeal rights was left with Administrator.