complaint·December 18, 2025

Continued from 9099... staff noted on 8/24/25 that “R1 continues to have a fever” and was given PRN Tylenol. Per regulation 87465(c)(3), a record of each PRN dose is to be maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. LPA requested the PRN MAR for R1 from the licensee, but licensee could not provide any PRN MAR for R1, instead licensee provided a MAR for prescription medications. However, MAR provided did not reflect the information required per regulation 87465(c )(3). Therefore, the facility could not show documentation that R1 was administered any medication on the day of 8/24/25 to address their fever and did not document R1’s outcome of receiving the medication, or if they ever actually received it. Complaint alleges staff did not notify resident's PCP of change in condition. During investigation, facility provided LPA with proof of faxed notification to R1’s primary care physician (PCP) dated 8/31/25. However, staff (S2) advised LPA that R1’s PCP never responded to any of S2's faxed requests. S2 said they called and got clarification as to why all the requests were being ignored or not answered. S2 explained to LPA that they were advised by staff at PCP office that fax is not the best way to communicate and may result in communication not being acknowledged or received. During investigation, LPA reviewed written evidence showing that S2 acknowledged that communication via fax to R1's PCP was not the best way to communicate. S2 acknowledges that they were advised as such from the PCP on subsequent faxes they sent to R1’s PCP. However, S2 continued to send requests to the PCP via fax as evidenced by faxes sent on 6/2/25, 6/8/25, 8/24/25, and 8/25/25. So, although facility had previously been advised that fax is not the best way to communicate they continued to communicate only through fax. Based on LPA’s interviews and record review, 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, are being cited on the attached 9099D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given .