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32 | On 05/13/2026 between 10:00am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and identified 42 undocumented medication administrations affecting eight (8) residents. The review showed missing initials for medications assigned to R1, including 6 missed doses of Carvedilol, 3 of Duloxetine, 14 of Furosemide, and 9 of Gabapentin on various dates in April 2026; R2 had 2 missed doses of Sacubitril/Valsartan, 2 of Magnesium Oxide, 2 of Vitamin C, and 1 multivitamin dose between April 10–18, 2026; R3 had 2 missed doses of AmoxClav, 1 of Olanzapine, and 1 Lidocaine patch between April 6–15, 2026; R4 had 2 missed doses of Polyethylene Glycol, 3 of Amlodipine, and 2 of Atorvastatin between April 12–20, 2026; R5 had 1 missed dose each of Benazepril, Eliquis, and Refresh Tears on April 9, 13, and 17, 2026; R6 had 2 missed doses of Divalproex, 2 of Vitamin D3, 3 of Docusate Sodium, 4 of Famotidine, 1 of Omega-3 Ethyl Esters, and 1 of Buspirone between April 5–22, 2026; R7 had 20 missed doses of Lantus Solostar, 3 of Metformin, and 2 of Xiidra throughout April 2026; and R8 had 2 missed doses of Levetiracetam and 1 missed dose each of Lisinopril, Sertraline, Acetazolamide, Bisacodyl, Ipratropium-Albuterol, Isosorbide Dinitrate, Jardiance, and Triamcinolone between April 7–25, 2026. The Department also observed nine (9) medications remaining inside bubble packs despite being initialed as administered, with no documentation explaining the discrepancies.
Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
Exit interview conducted with Catherine Dacara (Assistant Administrator) a copy of this report was provided with appeal rights. |