Complaint Investigation Report

Staff member S2 then arrived at the facility. W1 asked S2 to view the medication logs for medication-1. S2 provided the Pro Re Nata (PRN-given as needed) logs to W1 who photographed them. These photographs were provided to Community Care Licensing (CCL). The PRN log shows that medication-1 had been given to R1 sixteen (16) times between the dates of 3/26/2026 to 4/11/2026. R1’s medication list provided by Kaiser Permanente dated 3/23/2026 does not show medication-1 as a prescribed medication. The facility did not receive a doctor’s order for medication-1 until 4/3/2026. The PRN logs show the facility administered medication-1 that was not prescribed for R1 until 4/3/2026 on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026; 4/1/2026 and 4/2/2026. California Code of Regulations (CCR) 87465 (e) states, “For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.” Based on LPA’s observations, interviews 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 Chapter 8, are being cited on the attached 9099D.

Complaint alleges that staff do not ensure that resident’s medication is administered as prescribed. The bottle of medication-1 listed the following instructions on its label, “Take 1/2 to 1 tablet by mouth daily for ‘redacted’ up to 3 times a week. Use sparingly.” Within the week of 3/26/2026 to 4/1/2026 LPA observed that medication-1 was administered to the resident on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026 and 4/1/2026. As medication-1 was administered to R1 six (6) times in a week, the amount of medication administered exceeds the doctor’s orders as shown on the prescription label. In addition, the facility’s Centrally Stored Medication and Destruction Records for medication-1 were incomplete. The record was observed not to have the instructions, expiration date, date filled, prescribing physician, prescription number and number of refills listed. Furthermore, medication-1’s prescription label was observed to show that the medication should be discarded after 5/5/2022. Based on LPA’s observations, interviews 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 Chapter 8, are being cited on the attached 9099D.