Complaint Investigation Report

Regarding the allegation: Staff overmedicated a resident in care. During today’s visit, between 9:40 a.m. and 10:15 a.m., the LPAs conducted a review of medication and medication documentation with Administrator for four (4) residents and observed the following: Resident #1 (R1’s) Methotrexate Sodium 2.5 MG quantity (qty): 4 (Take 1 tablet by mouth every Wednesday for rheumatoid arthritis) was started on 12/28/2024 and had 1 tablet remaining, however, there should be a total of 3 tablets remaining instead. R1’s Melatonin 5 MG TABS qty: 30 was started on 12/28/2024 and had 12 tablets remaining, however there should be a total of 21 tablets remaining instead. Resident #2’s (R2’s) Lisinopril 20 MG Tab qty: 14 was started on 01/01/2025 and had 7 tablets remaining, however, there should be a total of 8 tablets remaining instead. Resident #3’s (R3’s) Ferrous Gluconate 324 MG Tab qty: 30 was started on 12/11/2024 and had 9 tablets remaining, however, there should be a total of 3 tablets remaining instead. R3’s Pantoprazole DR 40MG Tab qty: 30 was started on 12/11/2024 and had 9 tablets remaining, however, there should be a total of 3 tablets remaining instead. Based on observation, record review, and medication review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.