complaint·August 6, 2025

Upon review of R1’s facility file, documents show staff identified missing medication, two of which were Lasix and KCL (potassium). Both medications were listed on a physician’s verification form dated 1/23/23. Hospice Records state the following: Hospice charting visits on 3/1/23, 3/8/23, and 3/10/23 state: resident had edema, medications were reviewed, and caregivers demonstrated medication compliance. Additional notes from Hospice: 3/8/23: New note: “+1 edema noted to BLE (bilateral lower extremity)…3/10/23: New note: “3+ edema...and new fluid blisters noted to the top of (R1)’s feet.” 3/17/23: New note: “Pt encouraged to take (their) Lasix to assist with edema.” Hospice Medication list states Lasix and Potassium’s start date was 2/28/23. The facility's Centrally Stored Medication and Destruction Record (CSMDR) shows that “Furosemide” (Lasix) was ordered, filled, and started on 3/9/23, and potassium was started on 3/10/23. Correspondence confirms that an attempt was made by the administrators to get medication from hospice on 3/6/23. Both sets of messages confirm that the Lasix medication was received and given on 3/9/23. Correspondence received by LPA notes a conversation from the administrator, dated 3/9/23, which states the facility showed the Nurse Practitioner (NP) blisters on the top of R1’s foot. “It’s because of (R1)’s edema. Hopefully, when (R1) starts the Lasix, this will help (R1).” Nurse Practitioner notes on a “Physician Visits” form, dated 3/9/23, “Pt very SOB (short of breath). Increase Furosemide to 80mg Q am,” indicating the medication could assist in this symptom. When administrators were asked about the delay, they couldn't remember specifics due to the incident occurring over two years ago. Notes and messages indicated that the medication was discussed with the hospice nurse on 3/1/23 as missing. The administrator mentioned that the family brought part of the medication and was supposed to bring the rest. The administrator states they asked the nurse for the missing medication again on 3/6/23. Continue on 9099-C In an interview on 8/4/25, Hospice Nurse believed the family would bring the missing medication and admitted that the facility reached out on 3/6/23. Nurse did not confirm the medication was still missing until the second visit on 3/8/23. Hospice notes show that a rush order for Lasix was requested on 3/9/23. The hospice agency handbook provides that a pharmacist could assist with medication questions and there is a 24-hour hospice hotline, but no interviews or records show these resources were utilized. Records and interviews concluded that R1’s Lasix and potassium were not administered from 3/1/23 to 3/8/23. While attempts were made to obtain medication through hospice and the family, it is the facility's responsibility to follow physicians’ orders, ensure scheduled medications are administered, and arrange care appropriate to the conditions and needs of residents. Based on LPA’s observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.