Follow-up on corrections·August 6, 2025

Licensing Program Analyst (LPA) Rankin conducted a Case Management - Deficiencies visit to issue deficiencies on medication documentation errors which were discovered during a complaint visit. LPA met with the Administrator Freda Robles and Administrator Desingee Claire Aviado explained the purpose of the visit. During a record review conducted for a complaint visit on Resident 1 (R1), LPA noted that physician’s orders and medication lists from hospice do not match the facility’s Centrally Stored Medication and Destruction Record (CSMDR) or the Medication Administration Record (MAR). There are medications referred to in the hospice medication list that are not on the CSMDR, such as Albuterol, Omeprazole, Ondansetron, Tylenol, Folic Acid, Dulcolax, Senna, Hyoscyamine Sulfate SL, Coenzyme, and the high-risk medication Oxycodone. It was confirmed through the hospice agency that a “comfort kit” comes with Ondansetron, Dulcolax, Senna, and Oxycodone. Records and interviews concluded that R1 was admitted on 2/28/23 and that medications ordered by hospice were provided to the facility but not added to the CSMDR. It is the facility’s responsibility to ensure medications are prescribed by a physician, and that the record of dosages of medication, which are centrally stored, are maintained by the facility. Based on interviews conducted and record reviews, the facility did not maintain an accurate CSMDR. Medications sent to the facility and ordered by hospice were not noted on the CSMDR or on the MAR. 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.