Complaint·June 20, 2025

A review of R1’s care notes indicates that R1 started an antibiotic on 3/6/24, which was prescribed to be taken twice a day for 10 days. However, a review of R’1 Medication Administration Record (MAR) revealed that this antibiotic was given correctly in the PM dose from 3/10/24 to 3/19/24, completing the 10-day course in the PM. But in the AM, the medication was only administered for 9 days, missing one dose. R1 should have finished the dose in the morning of 3/20/24. Review of R1's Controlled Drug Records confirms one missing dose in the morning of 3/10/24. Additionally, R1 began another antibiotic on 5/9/24, which was prescribed to be taken twice a day for 10 days. The care notes showed that this medication was properly administered both in the AM and PM, with no issues or missed doses noted. However, another antibiotic, Nitrofurantoin (Macrobid), prescribed for 5 days, was not given as prescribed. The MAR shows that R1 only received the medication for 4 days in the AM (from 6/29/24 to 7/2/24) and 3 days in the PM, instead of the full 5-day course as directed by the prescription. Review of R1's Controlled Drug Record shows that this medication was initially given to R1 on 6/29/24 in the morning and last given on 7/2/24 in the morning. These discrepancies indicate that staff did not administer medications exactly as prescribed. The first issue was the missing AM dose in March, and the second issue occurred when the 5-day course of Nitrofurantoin was not completed as prescribed in July. Therefore, this allegation was SUBSTANTIATED. The above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099-D during this visit. LPA discussed plan of correction with the Administrator over the phone. Exit interview was conducted with Kaushik Sharma (in person) and Carley Taylor (via phone) to discuss the report and plan of correction. A copy of this report and appeal rights were provided. {2 of 2}