Complaint Investigation Report

LPA conducted a review of the medication for ten (10) residents during the visit today. LPA observed discrepancies for six (6) out of ten (10) medications and their Medication Administration Record (MAR) logs. LPA found that several of the medications were missing from the cart and/or were pending refills from the pharmacy. Other discrepancies included a medication for one resident was already administered for tomorrow, 6/24/26, and staff indicated the open date of 6/1/26. Additionally, the staff initial was not indicated for R1’s morning medications on 6/20/26.

Interviews with staff revealed that there are times when medications were not fulfilled timely due to pending physician authorization or that the pharmacy did not receive the on-cycle medications timely. LPA also interviewed ten (10) residents. Four (4) out of the ten (10) had issues with medications not administered due to staff not receiving the medication from the pharmacy.

Based on interviews conducted 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 and Chapter 8), are being cited on the attached LIC9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the Executive Director. A copy of this report and appeal rights were provided.