Follow-up on corrections·August 5, 2025

Licensing Program Analyst (LPA) Rankin conducted a Case Management - Incident visit to issue deficiencies on a medication error discovered during a complaint visit. LPA met with the Administrator and Wellness Director and explained the purpose of the visit. During record review conducted for a complaint visit on Resident 1 (R1), LPA noted that physician’s orders dated 6/2/25, received 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after an incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. MAR has the order written as “Give 1 tablet by mouth every 24 hours as needed for Pain DNE 1 tab in 24hrs.” Review of Facility care plan for R1 and Physician Report for R1 notate that R1 needed medication management from the facility Interview at 3:20 pm on 7/25/25 with prescribing Nurse Practitioner, LPA confirmed that the PRN order was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Images of medication were provided to LPA which show prescription label of “bedtime” and the order states as noted above that it is 1 tablet at bedtime as needed for pain. Continued on 809-C Based on interviews conducted and record reviews, the facility did not follow physician order when medication was given outside of the prescribed time frame. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D). An exit interview was conducted, a copy of the report, and appeal rights were issued.