complaint·March 15, 2023

another staff during the daytime shift. R1 received their PRN Lorazepam at 09:17AM. However, record review and interview revealed that R1 takes regularly prescribed medications at 10:30AM. Interview revealed that due to the timing of the medication, the electronic Medication Administration Record (MAR) has these medications listed under the noon medication pass rather than the morning medication pass. Interview revealed that after administering facility residents' noon medications, Staff #1 (S1) was reviewing the noon medication pass when S1 realized R1 had not yet received their 10:30AM medications. S1 then offered R1 their medications. Medications were recorded on the electronic MAR at 01:40PM indicating "resident refused." However, interview revealed that R1 did in fact receive their medications outside the designated morning time frame. Additionally, LPA conducted a medication review during today's visit beginning at 11:31AM. The following was noted: R1's Quetiapine Fumarate 25mg was opened on 03/07/2023 and initially contained 30 doses, as each dose is 1/2 pill. During today's medication review, LPA and Med Tech counted 22 remaining doses, which is one extra dose of this medication. MAR review revealed that there were no missed doses of this medication during the time frame indicated, with the exception of the late medications on 03/08/2023. Similarly, there were one extra remaining dose of R1's medications as follows: Gabapentin 100mg, Furosemide 20mg, Metopropol Succinate ER 25mg, Pantoprozole Sod DR 40mg, Potassium Chloride ER 8 MEQ, and Spironolactone 25mg. For each of the above listed medications, the dosage indicated under #11 in the bubble pack remains. As the MAR is initialed as administered, it is unclear whether R1 refused these medications or if the medications were offered to R1. Based on interview and record review, the allegation that " Facility staff did not assist resident with self-administration of medications as prescribed" is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.