Complaint Investigation Report

502700235-1-8-2024-27-AS-LRIS-CZD38A-20240110170114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SACRAMENTO SOUTH ASC , 9835 GOETHE ROAD, SUITE 100

This is an official report of an unannounced visit/investigation of a complaint received in our office on

10/11/2023 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20231011111327

Staff mishandled a resident's medications while in care

On 1/8/24 at approximately 2:00pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with the Resident Care Director Caress Brown and explained the purpose of today's visit.

LPA Jensen reviewed the Medication Administration Record (MAR) for Resident 1 for September of 2022. It documents that an ACE inhibitor was prescribed and not given from 9/16/22 through 9/25/22. There is no explanation on the MAR as to why the prescription was not administered. According to R1's responsible party, R1 ran out of medication on 9/15/22. It is unclear why the resident missed ten doses of the ACE inhibitor. It is evident that the resident was present at the facility on these dates based on the MAR showing that other prescribed medications were administered therefore the allegation of "staff mishandled a resident's medication while in care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and appeal rights given.