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32 | The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room.
The investigation revealed the following:
Allegation: Staff are not dispensing medication as prescribed. It is being alleged that the facility is not administering a resident’s medication as prescribed. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff administer the resident’s medication on time and as prescribed by their physician.
On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff administer their medication on time and as prescribed by their physician, and 2 out of 9 residents said staff do not administer their medication on time and as prescribed.
On 07/23/25, the department reviewed MAR’s for R1, R3, and R4 for the months of March, April, and May 2025. The records revealed discrepancies, and various medications were missed on various dates for R1, R3, and R4, for the months of March, April, and May 2025.
Based on evidence gathered, interviews conducted, and records reviewed, 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. Please see the attached LIC 9099-D.
An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern.
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