Complaint Investigation Report

The investigation revealed the following:

Allegation - Resident missed medication. It is alleged that residents have missed medications due to medications not being refilled on time. LPA interviewed Staff and Residents for this allegation. Three of the med techs stated that residents may have missed their medications due to pending physician’s approval for the refills. Staff stated they would order refills about 7-10 days prior to medications running out. Staff noted that self-managed medications are refilled by the residents themselves. Residents interviewed stated that the facility manages their medications and do not believe they have missed any. LPA reviewed medications for ten residents. Two out of the ten residents have at least one of their medications for which they have a physician’s order to self-manage. Staff stated they would assist with ordering refills if residents asked. LPA reviewed Resident #3’s medications with the medication administration record (MAR). It appeared that the medication Alendronate Sodium 70 MG tablet was prescribed once a week in June 2025 and was indicated on the MAR log with the staff’s initials. However, the medication could not be located in the med room/cart. LPA confirmed with the staff that the medication was not available in June because the refill has not been obtained by the family member. There were no staff notes available for this medication to follow up on a refill.

Based on LPA observation 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 LIC 9099D.

An exit interview was conducted. A copy of this report, a plan of correction, and appeal rights were provided.