complaint·September 20, 2023

Interviews conducted with ED, as well as staff members S1 and S2, indicated that resident (R1) was discharged from the hospital with new medication orders on 9/8/2023 which were not delivered to the facility until the evening of 9/9/2023. LPA observed text message correspondence amongst staff members indicating that new medications for R1 did not arrive at the facility until the evening of 9/9/2023. Interview with S1 indicated that they contacted R1's hospice care agency on 9/9/2023 regarding the medications not being delivered to the facility. Interview with S1 was inconsistent as to whether they contacted R1's hospice care agency before or after speaking with R1's responsible party regarding the missing medication. LPA reviewed Shift Reports and observed that it was noted under NOC shift notes for 9/8/2023 that new medications for R1 were delivered by the pharmacy to the facility during NOC shift on 9/8/2023. Interviews conducted indicated that the documented date for when medications were received was incorrect. During a visit conducted on 9/19/2023, LPA conducted a medication count for resident R1, comparing the resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA observed two (2) medications for R1 that were off count in relation to what was documented. Both medications that were off count were under the amount documented when taking into account any medication refusals documented for R1. Based on interviews conducted, a medication count, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $250 is assessed for the date of 9/20/2023 for a repeat violation within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.