Complaint·June 7, 2024

While reviewing resident R1's medications, LPA and ADM discovered a discrepancy. Medication #1 has a start date of March 12, 2024. The instructions are 3 tablets, 3x a day, which would result to 9 tablets a day total. The total pill count for this medication is 900. The Centrally Stored Medication Log and the ADM stated the facility has administered the medication for 44 days since March 12. (44 days x 9 pills=396 + the 3 pills that have been given this morning=399). ADM counted the remaining number of pills in the container, which totaled 556 pills. (556+399=955, A total of 55 excess pills.) ADM acknowledged that there have been instances where 1 pill was given instead of 3 and she has informed R1's responsible party. On June 7, 2024, LPA interviewed staff S1 and S2. S1 states he/she doesn't know why there was an excess of 55 pills. S2 stated he/she did miss giving out R1's medication #1 sometime for the month April, in the afternoon pill passes. LPA interviewed facility ADM. ADM stated R1 did not have any hospitalization's since R1 moved into the facility. ADM stated R1 has not had any overnight stays since he/she moved into the facility. Based on a review of R1's physicians report, dated September 18, 2023. R1 cannot manage his/her own medication. Based on a file review, there are no incident reports regarding R1 stating he/she had any hospitalization's or medication errors since R1's admission. Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Anabelle Ablan and a copy of the report was provided. Appeal Rights was provided. LPA Monter interviewed residents R1-R5. Resident R1 stated he/she had a fall but did not give an answer to when or where he/she had a fall. R2 and R3 stated resident R1 has not had a fall. Resident R4 stated he/she did not want to be interviewed. Resident R5 did not respond to LPA’s questions and is nonverbal. On May 7, 2024, LPA interviewed Witness W1. W1 stated he/she visits the facility weekly to see R1. W1 stated he/she has not observed any signs of R1 sustaining a fall since R1 moved into the facility. On June 7, 2024, LPA interviewed ADM. ADM stated R1 does leans forward in general when he/she seated in the wheel chair. ADM stated R1 will also lean forward when eating at the kitchen table or using his/her Ipad. ADM stated staff is present in the facility and have not observed R1 fall. A review of R1's Admission Agreement shows, R1 moved into the facility on September 23, 2023. A review of R1's physician's report, dated September 18, 2023, states R1 is non-ambulatory, based on physical condition. The form states R1 will not ask for help and attempts walking. A review of R1's Pre-Placement Appraisal, dated September 23, 2023, states R1 uses a wheel chair, but cannot get in and out unassisted. Based on a File Review, there are no incident reports regarding R1 stating he/she had any hospitalization's or falls since admission. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 2 Out of 2.