Complaint Investigation Report

handle all of R1's own medical and dental appointments with assistance from the facility staff if requested by R1.

Based on a review of the facility Medication Administration Record (MAR), it was observed that from the months of February 2024 until November 2024, there weren't any entries, with initials, in regards to the resident R1 taking, refusing, or missing R1's medications for this duration of time. It was observed that there weren't any supporting notes or comments entered into the MAR for this resident at all. It was learned that this LPA was left to assume that the prescribed medications were not properly dispensed, handled, and documented during this span of time for the resident R1 since there wasn't any documented proof of facility staff dispensing the medications to R1..

Based on a review of the facility forms and documents, it was learned that R1 was deemed to be unable to manage and store R1's own medications per the LIC 602 that was completed and signed off by R1's attending licensed medical professional at that time.

Based on a review of the facility forms and documents, it was learned that R1 was deemed to be able to handle R1's own medical needs with setting appointments, going to and from appointments, and follow up as needed. It was learned that R1 was still unable to be able to manage R1's own medications and required that this facility had to properly handle, dispense, and document them at this time.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.