Complaint·February 24, 2023

Records review also revealed the facility’s Medication Administration Records (MARs) for R2 indicated R2 was receiving medications as prescribed, by staff daily initialing the MARs as dispensed for the month of November 2022. Interview with facility staff revealed an internal facility investigation was conducted. The medication for R1 and R2 was counted and compared for; morning, evening and bedtime and all of the medications had the same, correct amount. It was determined that the medications were "popped" on different dates which is why it was believed that the medications were not distributed to R1 and R2. Interview with facility staff further revealed that discontinued medication for Resident 3 (R3) was stored in the same drawer with the "active" medications. As a result, the discontinued medication was distributed to R3 on November 2, 2022. Staff noticed the handwritten note on the medication bottle indicating it was discontinued after dispersing to resident. Interview with Executive Director revealed R1 and R2 were given all of their medications by facility staff. The medications were given from the "new card of medications" as opposed to the last of the medication from the "ending card." Executive Director further stated that medications are received in a monthly cycle, so the medication was dispersed from the upcoming month. Executive Director stated that R3's doctor was notified (on November 2, 2022) of the resident receiving the discontinued medication in error. Records review revealed R3 was placed on 72 hours alert charting on November 2, 2022. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22 and are noted on the attached LIC 9099-D. An exit interview was conducted with Angela Scott Kaplioff and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Angela Scott Kaplioff whose signature below confirms receipt of documents. Furthermore staff stated that it takes approximately 2-3 minutes for the alarm to be reset and all staff would be aware of any resident elopement. Interview with R4's spouse R5 revealed they have both lived at the facility since November 2021 and R4 is never out alone in the facility. R5 further stated that R4 has never exited the facility alone and R5 knows this for a fact since R4 is always with R5 when R4 leaves the memory care unit. Interview with Executive Director revealed R4 is always monitored by front desk staff when out of the memory care unit. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Angela Scott Kaplioff and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Angela Scott Kaplioff whose signature below confirms receipt of documents.