complaint·October 28, 2025

Medication is being mismanaged. - UNSUBSTANTIATED It was reported that staff are not administering a resident's medication and did not fill a resident's prescription. LPA reviewed Resident Observations notes for R1. On 08/28/25 R1 was transported to hospital for evaluation for rash on face and was diagnosed with shingles. 08/29/25 the infection progressed and worsened. On 08/31/2025 R1 complained of pain, PRN Tylenol dispensed. 09/01/25 Tylenol was dispensed and effective. 09/02/25 No complaint of pain or fever. 09/09/25 R1 requested Tramadol for pain, states Tylenol not working, states in extreme pain. 09/05/2025 Med Tech faxed physician for advice. 09/21/2025 through 09/30/25 R1 did not complain of pain. LPA reviewed Medication Administration Record (MAR) for Resident 1 (R1) which shows on 08/29/2025 Erythromycin Ophthalmic Ointment 5 MG/GM, and Valacyclovir anti-viral were added and dispensed the same day. Erythromycin Ophthalmic Ointment was discontinued on 09/05/2025. Valacyclovir was discontinued on 09/06/2025. MAR includes prescription for Tylenol 500 mg with PRN care notes on 09/21/25 and 09/26/2025 “Not effective”. LPA reviewed a written request dated 08/14/2025 from R1’s physician to the pharmacy requesting that Tramadol be discontinued at R1’s request and R1 was “OK with Tylenol”. There are no new orders to start Tramadol for R1 after this discontinuation. LPA reviewed a fax dated 09/05/2025 from med tech to a health clinic requesting advice regarding R1 requesting to speak with their physician about using Tramadol instead of Tylenol as the Tylenol was not helping. On 09/10/2025 Doctor responded that R1 requested to discontinue the Tramadol at their last monthly appointment and stated that Tylenol was fine. Doctor advised if R1 had any concerns they should schedule a telehealth appointment. Staff interviews confirmed that R1 had a prescription for Tramadol but the medication was discontinued. Executive Director stated R1 was prescribed antibiotic eye drops and oral antibiotics for 7 days. R1 had a prescription for Tramadol but it was discontinued by their physician on 08/01/25. R1 refused telehealth appointment with primary care physician to discuss renewing their Tramadol prescription. No new orders for pain medication were received for R1. It was determined that R1’s prescription for Tramadol was discontinued by their physician at R1’s request. R1 refused a telehealth appointment with their physician to renew their Tramadol prescription. No new orders were received for Tramadol or any other pain management medication for R1. This allegation is unsubstantiated. Facility is not providing adequate food service to residents. - UNSUBSTANTIATED It was reported that the food is not healthy and is always cold. LPA reviewed daily photographs of meals that the residents have recently been served and found them to look acceptable. Staff stated that some residents complain about the food in general but they do not say the food is cold. Executive Director stated In February 2025 the facility bought a hot box and have not had any complaints since. Staff serve the lower hall first and then take the hot box to the upper service area and it is plugged in and the meals are served hot. They take the serving dishes in the hot box and staff plate the food for each resident. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to executive director Stacey Baxter.