complaint·July 20, 2023

9099C-1... One staff stated medications are sometimes not ordered timely, explaining each Med-Tech is in charge of ordering medications. Staff explained that the facility previously tried a system of ordering 7 days out, but it didn't work, and sometimes a resident will not start an antibiotic medication until the next day and they receive their first dose at the hospital. (1) resident who was interviewed stated he has not had any issues with receiving medications and they are the same every day. Medication being left out. LPA toured the facility on 6/28/23, 7/6/23, 7/13/23 and 7/20/23 and did not observe any unsecured medications to be on the floor or in the resident hallways. Staff interviewed stated medications are delivered using the med cart and usually "we administer them in the dining room- there are more eyes on the meds with dining staff there". LPA observed both dining rooms on 7/20/23 and did not observe any medications on the floor during/after S1 administered noon medications to a few residents. LPA and S1 conducted a medication audit for (3) residents on 6/28/23 in the facility medication room. Medication orders were compared to medications being administered and documentation on the Centrally Stored Medication List (LIC622) and Medication Administration Record (MAR) was reviewed. The following discrepancies were noted for (2) residents, as follows: For resident (R1)- There were no errors in (11) of (15) medications. Medication counts on hand did not match with the start date entered on the LIC622 for Cranberry supplement, Multi-Vitamin Centrum, Divalprox and Olanzapine, showing a discrepancy of (2) to (12) days. There was no start date listed on the LIC622 for Senna 17.2 mg and PRN Olanzapine, 5mg- expired 4/12/23. New medication of Olanzapine was ordered on 7/8/23 and will be received by 7/28/23. S1 stated resident has not taken this recently as it has not been needed. There were (2) lose pills observed in resident's red centrally stored box that appeared to have fallen out of the bubble pack. Medication was discarded per protocols. For resident (R2)- there were no medication errors noted on (3) of (3) medications and there were no lose pills in the red centrally stored box. For resident (R3)- There were no errors in (5) of (7) medications reviewed. The medication Fluoxetine 20 mg was missing (1) tablet based on the start date and medication count . The medication Risperidone 0.5 mg, ordered to be given as (1) tablet in the morning and (2) at bedtime, a start date of 6/10/23 was noted on the LIC622. There was no start date entered on the 30-day bubble pack. (13) tablets were administered on 6/28/23 (4:00 pm), or (4) days plus a morning dose, if administered as ordered. The medication count didn't match the start date entered on the LIC622. There were no lose pills in resident's red centrally stored box. cont on 9099C-2. 9099C-2... Based on information obtained and reviewed, LPA finds the allegation 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. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided.