complaint·November 15, 2021

...Continued from LIC 9099 On 09/28/21, LPA Valerio interviewed Staff 1 (S1). When asked if S1 knew if any residents are not getting their medication as ordered by a physician, S1 confirmed that S1 knew of an incident that occurred on 09/25/21. S1 stated that a medication technician called out from work, which left the facility short staff. S1 stated there were residents in hallway 3 that did not receive their medications. S1 admitted that S1 did not send an incident report to licensing. On 09/28/21, LPA Valerio interviewed Staff 2 (S2). Staff 2 reported that prior to S2 being employed with City Creek Assisted Living, the facility had many issues with pharmacies bringing medications to the facility. S2 reported that since being hired, S2 did not observe residents not getting their medications due to staff forgetting to give the medication. S2 stated if a resident does not get their medications, "it is simply due to the pharmacy not having it." On 10/14/21, LPA Valerio interviewed two residents (R1 and R4). R1 stated, "In the last three weeks, I have not had my medications three times. I go to try to get my medications and the nurses are nowhere to be found. Once I finally find a staff, they say that the medications are locked up and I can't get it. I wait hours until I finally get the medications." R4 informed LPA that R4 did not receive medications from staff and did not know the reason for it. LPA Valerio reviewed resident files for Resident 1 (R1) - Resident 4 (R4). LPA Valerio observed R1 did not receive a controlled medication on 08/13/21 due to staff forgetting to give it. Resident 2 (R2) file was reviewed. R2 did not receive a medication order on 08/02/21 - 08/05/2021 due to waiting on pharmacy. Resident 3 (R3) file was reviewed. R3 did not receive three orders of medication for the entire month of August due to conflicting reasons: Waiting on Pharmacy, Resident Refused, and Withheld per DR/RN Orders. Resident 4 (R4) file was reviewed. R4 did not receive a medication on 10/04/21 - 10/16/21. On 10/12/21 - 10/16/21, R4 received the medication at 8:00 AM and at 12:00 PM. However, at 4:00 PM on 10/12/21 - 10/16/21, the reason for not receiving the medication was the facility was waiting on the pharmacy. Based on medical record review, interview, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was provided to facility staff Caleb Summerhays.