Complaint Investigation Report

~In R1's MAR there was an order for perscribed morphine in tablet form which is filled out as distributed appropriately according to the order,

~In the resident R1's discharge notes from 5/7/26 Almond Vista, the prescription reads as 1 per 12 hours, no modulation asterisks for a hold, no language indicates an "as needed" basis.

~In record review, it was learned that S1 had filled out at least one MAR(R4) log with entry's where they described themselves as being out of the facility, in interview S1 stated they had falsely entered into the MAR that they had distributed medication when it was not them who distributed the medication, and was not here in the facility to witness if the medication was distributed.

~602 for the resident indicates the ability to administer their own medication, not being coginatively impaired, and the ability to commuicate needs, and past medical history indicates multiple sources of chronic pain (fractures)

~Needs and services plan, indicates R1 needed all ADL's assistance due to pain

~The controlled substances log does not have a morphine entry

~ A record review of the MARs of 5 clients can't support the missing medications for any resident, but also is being filled out by a staff after the fact, difficult to tell whats true

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.)

Citation was issued on the following D page, a copy of the report was read and given to the staff designated by the administrator. appeal rights provided, an exit interview was conducted.