complaint·March 25, 2026

Regarding the allegation: Staff did not ensure medications were dispensed as prescribed. It was alleged that staff did not administer R1’s medication as prescribed. To investigate the allegation, LPA conducted interviews with one (1) resident and three (3) staff members. LPA’s interview with R1 revealed the morning of 3/13/2026 they did not receive their medication due to staff not being available. R1 stated their prescriptions do not state their medication should be given to them in the timeframes of: morning, afternoon and bedtime, but instead their medication is labeled as “daily”. Additionally, R1 stated they did take their medication upon returning in the afternoon. LPA’s interview with all three (3) staff members confirmed R1 did take their medication on said date. LPA’s interview with S2 revealed, R1 has made it difficult for them to administer their medication due to them wanting their medication at different times of the day. LPA’s interview with two (2) staff members correlated with S2’s interview. When LPA questioned if any staff members dispensing medication were absent during their morning shift on 3/13/2026, all three (3) staff members denied. During LPA’s record review, LPA observed the staff schedule for 3/13/2026. LPA observed both S2 and S3 to be scheduled the morning of said incident. Further record review of R1’s MARs dated 3/13/2026 confirmed their medication was given and signed off. LPA’s supplementary record review of R1’s medication (2/18/2026 to 3/17/2026) revealed that although eight (8) of their medication was observed to be prescribed as “daily”, a web search of all eight (8) medications revealed the medications are advised to be taken in the morning to reduce potential side effects. LPA’s web search of the additional three (3) medications prescribed as (morning, afternoon, evening) revealed said medications could be taken later in the day if not in the morning. During LPA’s physical plant tour, LPA observed R1’s medication to be centrally stored within the locked medication room. LPA did not observe any discrepancy of R1’s medication. Additionally, a complaint was also filed against the facility for the alleged allegation under complaint control number 31-AS-20230621160636 dated 06/21/2023 revealed the findings of the investigation to be unsubstantiated at the time. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.