complaint·January 9, 2024

Continued on LIC9099... Based on records review, the facility provided during LPA's visit an incident report dated 12/5/23 indicating the following: “R1’s medication name Sertraline did not get order and R1 was not taking it. Once, we realized that there was an error in our ordering system, the error was corrected, the medication was ordered, and R1 is taking their medication as prescribed”. The facility also provided LPA with the Centrally Stored Medication Log (CSMR) for involved resident, which revealed that Sertraline 100mg/2 times per day (200 tabs supply) date filled was 3/3/23 and the next order was filled until 11/10/23, confirming that R1 was not assisted with the medication since June 2023. Based on interviews conducted with facility staff and outside parties. It was also discovered that the way that the facility is managing resident’s medications was a system where each resident’s medications were placed in their own "little box", and staff were supposed to look at the medication bottle to determine when a refill was due, but in R1's situation they never looked at the refill date so R1 was suddenly no longer getting their Zoloft. This medication is a very dangerous antidepressant due to people are supposed to gradually wean off them and not to be discontinued abruptly as occurred in this case. During records review of facility medication management protocol, it was revealed that the facility has a designated medication technician (S1) responsible for coordinating medication orders and ensuring that they are delivered in a timely manner. However, the designated med-tech is no longer working at the facility. Also, the facility have not contacted a pharmacy to review their medication management at least twice per year as required by regulation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.