Complaint·November 24, 2025

Regarding allegation: Staff are not distributing resident's medication as prescribed. It is alleged that the facility is not properly distributing residents in care with prescribed medication. The investigation reveals the following: Interview with ten (10) out of ten (10) residents denied the above allegation. All residents stated that staff has not ever missed any medication. R5 stated that R5 has observed staff coming to dining area to distribute prescription to residents. R5 added that staff “never ever forgot to give wife medication.” R5 added that staff is very conscientious about medication. R4 stated that residents complain about food, but R4 has never heard any complaints about prescription not being administered to residents. LPAs interviewed W1 who stated that staff has responded to R1’s call for assistance in a timely manner. In addition, W1 stated that staff have never forgotten to give R1’s medication. Interviews with staff revealed that ten (10) out of ten (10) staff denied above allegation. Interview with staff revealed that following staff has a two-hour window before and after the prescription is scheduled to be distributed to residents. Staff try to locate residents by phone or search in common areas. If resident is not located, charge nurse is notified and charge nurse reports it to doctor for missed medication. S1 stated that after two-hour window, the prescription is destroyed and missed medication is documented in the Stored Medication and Destruction Record. S1 stated that medication is destroyed in order to prevent Med Tech confusion and to prevent residents from receiving a double-doses for the next medication dose. Staff stated that residents who are going to be absent from facility are given prescriptions to take with them, and family is instructed to distribute prescription to residents. LPAs reviewed three (3) residents’ prescriptions and did not find any health and safety risks to residents in care. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility is distributing resident’s medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held with Erika Castile, Vice President, COO. A copy of the report was provided.