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32 | Administrator Carter was interviewed and reported that medication technicians/wellness director are trained and required to contact a resident’s responsible person approximately 7-14 days in advance to request a medication refill prior to a medication depleting to allow sufficient time for the refill to be delivered to the facility promptly. Administrator was unable to locate any record to prove that R1’s responsible person was contacted to request a refill for M1 on or around February of 2026.
LPA reviewed R1’s physician’s report dated 12/10/2024 documenting R1 exhibits memory loss and requires medication management. LPA reviewed R1’s Resident Service Plan listing their date of admission as 02/27/2025 also noting R1 requires medication management.
LPA reviewed R1’s physician’s order for M1 dated 12/15/2025 and M2 dated 01/20/2026. LPA reviewed R1’s Centrally Stored Medication and Destruction Record (CSMDR) documenting the facility received 30 tablets of M1 on 01/13/2026 followed by 90 tablets on 03/13/2026. However, the CSMDR does not note the facility received a refill for M1 on or before 02/12/2026. The CSDMR also notes the facility received 90 tablets of R1’s M2 on 01/20/2026.
LPA reviewed R1’s MAR for February of 2026 which documents R1 received M1 and M2 as prescribed during the entire month. LPA also reviewed R1’s MAR for March of 2026 and noted M1 and M2 have 14 dates where the staff initials are circled in the section that is used to document whether the medications were administered. Administrator Carter explained that circled staff initials in the MAR indicate the medication was not given due to reasons such as the resident being out of the facility or the facility awaiting medication delivery. LPA reviewed the R1’s MAR exception which documents the reason for not dispensing the medication on the 14 dates as, “Awaiting Delivery”. Administrator Carter reported, “Awaiting Delivery” refers to facility staff waiting for medications to be delivered to the facility. However, the CSMDR notes the facility received 90 tablets of R1’s M2 on 01/20/2026 which did not require to be refilled until 04/20/2026. LPA also reviewed a photograph dated 04/18/2026 of R1’s M2 that contained at least 20 tablets in the medication bottle. There is no record or report that R1 received physician orders to discontinue M1 or M2 during the time the MAR for March of 2026 notes R1 did not receive the medication.
Based on 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, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, Confidential Names list (LIC 811) and Appeal Rights were reviewed and provided to Administrator Carter.
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