complaint·December 11, 2025

Regarding the Allegation: Licensee changed a resident’s insurance without the resident’s or responsible party’s authorization. It was alleged that a facility staff member modified the resident’s health insurance without consent from the resident or their responsible party. LPA and LPM interviewed five staff members out of a total of 45. Interviews indicated that any changes to a resident’s health insurance must be initiated by the resident and/or their responsible party. During an interview with Staff 1 (S1) stated they were unaware of who made the changes to the medication portion of R1’s health insurance and explained that such modifications are typically handled between R1’s Power of Attorney (POA) and the pharmacy. Interviews with W1 and W2 did not confirm who made the changes to R1’s medical insurance; however, both stated that the facility was not responsible for the alteration. Interviews with the resident were not able to confirm this allegation. Regarding the Allegation: Staff did not assist the resident with their medication. It was alleged that staff failed to package a one-day supply of R1’s medications, resulting in a shortage, particularly at the end of the month. It was further alleged that the facility refused to transport medication to address the shortage. LPA and LPM interviewed five staff members and residents. Interviews confirmed that the pharmacy provides medications in blister packs covering an entire month, and refills are typically ordered one week in advance to prevent any interruption in the medication supply. It was determined that R1 went on a home visit during the middle of a medication cycle, and the POA had been informed that the medication for the upcoming month was not yet available due to the holiday week. During an interview with S1, S1 stated they did not transport the medication because no authorized individual was available to deliver it, that such transport is not standard practice unless the facility is at fault for a medication error, and that they were not comfortable with the request to send the medication via “Uber” while R1 was on a home visit. Interviews with the resident were not able to confirm this allegation. Continued on 9099-C Regarding the Allegation: Medication staff not properly trained. It was alleged that a Medication Technician (Med Tech) was not properly trained in preparing medications for residents who leave the facility for outings. Staff interviews indicated that Med Techs receive training from both a virtual Registered Nurse (RN) and an onsite Licensed Vocational Nurse (LVN). Training includes medication administration procedures and certification requirements. During an interview with S1, it was reported that the facility recently implemented a new system intended to reduce medication-related issues for residents who go on home visits. A review of training records confirmed that Med Techs receive three to six weeks of training, including shadowing. Interviews with the resident were not able to confirm this allegation. Regarding the Allegation: Licensee retaliates against the resident. It was alleged that the facility retaliated against the resident. Interviews with R1, residents and staff unanimously denied this allegation. Based on interviews, record review, and all information gathered, the above allegation(s) are determined to be UNSUBSTANTIATED . Exit interview was conducted, and a copy of this report was provided to the Assistant Administrator.