complaint·October 9, 2025

between both these two residents, has occurred by the same staff, Staff 1 (S1) in the past. S1 was trained and instructed to review and differentiate both these residents medications when packing, but S1 made the same mistake. Interviews with both administrator and one (1) of one staff were held between 9:15am-10:15am to discuss the package, preparation and distribution of resident medications during outings. At around 10:15am - 12:15pm, LPA conducted a physical plant inspection of the medication room to observe and review centrally stored medication and medication documentation. LPA attempted to interview six (6) of six residents between 12:15pm to 1:00pm, but due to the diagnoses of these residents, LPA was unable to get a consistent interview. Although corrections are in place to address this medication error, based on the information obtained, the allegation of staff providing or packing the wrong medication for R1 is Substantiated . Citation issued on the 9099D. Administrator advised and a copy of this report issued.