complaint·December 19, 2025

Regarding the allegation: Staff did not dispense medication as prescribed. It is alleged that on 07/12/2025, approximately at 10:00AM, med tech (S2) erroneously administered a blood pressure medication to the R1 that was not prescribed to R1. To investigate this allegation LPA conducted record review and interviews with five (5) staff members and R1. The medication error was recognized at approximately 12:30PM. S2 attempted to contact R1's primary care doctor (PCP) but there was no response. S2 was advised to contact the paramedics. Paramedics arrived and transported R1 to hospital due to hypotension. R1 later returned to the facility on 7/18/2025. Facility submitted an LIC 624-Unusual Incident/Injury Report (UIR) to LPA regarding the incident. In addition, S1 revealed that due to the error, said S2 was removed from their duties as a med tech and is currently working as a care giver. S1 mentioned that facility has updated their process of medication administration by adding resident's pictures, name and room number on medication cups. Based on interviews with facility personnel and record review, there is sufficient evidence to prove the alleged allegation did occur, therefore the allegation is SUBSTANTIATED . Citation, Civil Penalty and Appeal Rights were provided. Exit interview conducted and a copy of this report was provided.