Complaint Investigation Report
Allegation: Resident not assisted with medications as prescribed.
The details of the complaint alleged that facility did not follow (R#1)’s prescribed medications order.
On May 29, 2025, at approximately 3:00 PM, during a records review, LPA Iniguez observed Resident #1's Medication Administration Records (MARs) for April 2025. LPA Iniguez noted that the medication order for Ferrous Sulfate 325 MG Tablet prescribed one tablet to be taken by mouth once daily on Mondays, Wednesdays, and Fridays until April 23, 2025, when the physician discontinued it. However, facility staff documented on the MARs that they administered the medication to (R#1) for nine consecutive days, from April 14, 2025 (Monday) to April 22, 2025 (Tuesday). LPA Iniguez found that facility staff did not follow the prescribed medication order for (R #1). Moreover, LPA Iniguez reviewed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated: 8/19/24, it is noted that (R#1) is not able to administer their own prescribed medications.
On May 29, 2025, at approximately 10:00 AM, during an interview with the Administrator (A#1), she stated that there is an ongoing investigation to determine why the facility did not follow up on the order.
On May 29, 2025, at approximately 2:00 PM, interviews with facility staff (S#1-S#3) revealed that all (3) staff members did not follow up on (R#1)’s medication order prescribed by their physician.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction