Complaint Investigation Report, 04/15/2026 — Mountain Top

Allegation: Staff did not dispense medications as prescribed

Record review of Medication Administration Record (April 2026) revealed Client #3 (C3) received Pantoprazole Sod Dr 40 MG from 04/01/26 – 04/15/26 AM. LPA observed Pantoprazole Sod Dr 40 MG in the bubble packet for 04/07/26. LPA revealed the discrepancy to Staff #1 and Staff #4. One out of three witnesse (W1 – W3) interviews indicated complaints have been made about medication not being dispensed as prescribed.

Regarding the allegation, “Staff did not dispense medications as prescribed,” based on record review and observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Allegation: Staff did not follow required medication destruction procedures

Record review of the facility’s medication policy revealed medication which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. Both shall sign a record, to be retained for at least one year, which lists the following: name of the client, the prescription number and the name of pharmacy, the drug name, strength and quantity destroyed, and the date of destruction… Record review of Client #1’s (C1) Centrally Stored Medication and Destruction Record (CSMDR) (December 2025) revealed Gamma Aminobuturic Acid and Buspirone was disposed on 12/01/25 and it does not include a witness signature. Aripiprazole and Benztropine was disposed of on 12/06/25 and it does not include a witness' signature. Review of Client #2’s (C2) CSMDR (February 2026) revealed melatonin was disposed of on 02/11/26 and it does not include a signature. CSMDR (December 2025) revealed Gummies were destroyed on 01/02/26 and 01/08/26 and it is missing signatures from a representative and witness. Review of Client #4’s (C4) CSMDR (January 2026) revealed Lamatrigine 100mg was disposed on 01/17/26. It does not include a witness’ signature. Review of CSMDR (December 2025) revealed Hydroxyzine HCL was disposed on 12/05/25 and it does not include a witness' signature. Lamotrigine 25 MG was disposed on 12/19/25 and it does not include a witness' signature. Staff #1 (S1) indicated Administrators and Leads handle the destruction of medication, it is documented in the binder, and taken back to the pharmacy. Interview with Staff #2 (S2) indicated medication is stored in locked cabinet until it is destroyed. S2 indicated staff has tried to send medication to the pharmacy but the pharmacy sends it back. Interview with Staff #3 (S3) indicated Administrators handle the destruction of medication; however, MedTechs will document it, inform the Administrators, and place the medicine back into the container.