Complaint·September 24, 2025

move in. LPA reviewed R1’s Centrally Stored Medication and Destruction Records, Medication Order Summary Report, and the Medication Administration Record (MAR) which did not indicate the facility had a medication order for Cefadroxil 500mg capsules and there was no entry for the medication. Interview with ED indicated that they do not typically pass medications, however, they did one time when R1 moved into the care home. Interviews with S1, staff (S3), and witness indicated that ED provided R1 with their Cefadroxil 500mg capsules. Interviews with S1, S3, and staff (S4) indicated that typically the nurses and med techs pass medications. Interviews with S1, S2, and witness indicated that there were no medication orders for R1’s Cefadroxil 500mg capsules. According to facility’s Plan of Operation, “a resident may self-administer his or her own medications only when there is proper documentation from the physician”. The Plan of Operation also indicated that the facility is to “maintain a current residents with self-medication orders form in the Wellness Center”. To date, the facility was unable to provide LPA with a medication order for R1’s Cefadroxil 500mg capsules. Interview with ED indicated that they have taken medication training as they are the ED of the care home. Interviews with S2, S4, and witness indicated that the facility has a policy to complete medication training if staff are going to be passing medications to residents in care. Interviews with S4, witness, and Business Office Coordinator indicated that the facility has required Medication Management training that staff are to complete if they will be passing medications. Upon review of ED’s training documentation that was provided, the ED does not have current medication management training. According to the facility’s Plan of Operation, “team members administering medications must fall under one (1) of the following areas: A licensed health care professional, has successfully completed a state approved medication training course, has completed a Sunrise medication training program, if a state approved medication training course is not required”. To date, the facility was unable to provide LPA with the ED’s current medication training documentation. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided.