Complaint·January 29, 2026

Allegation: Staff did not ensure residents received their medication in a timely manner. It was alleged that facility staff failed to ensure residents received their medications in a timely manner. The Reporting Party (RP) stated that on 1/25/26, the facility had no Medication Technicians (Med-techs) on duty throughout the day, resulting in medications being administered at approximately 5:52 p.m. RP further reported that residents did not receive their scheduled morning and afternoon medications and that staff were overworked and working double shifts. To investigate the allegation, the Licensing Program Analyst (LPA) conducted a review of facility records and interviewed the Executive Director (ED), Business Office Manager (BOM), two Med-techs, and eight (8) residents. During the interview, the ED confirmed that on 1/25/26, there was a staffing conflict and a staff call-out for the Assisted Living (AL) unit’s morning Medication Technician (MT) shift. This resulted in a delay in administering morning medications. The ED also stated that Resident 1 (R1) did not receive their morning medication because the delayed administration time was too close to the scheduled afternoon medication pass, making it unsafe to administer both. Interviews with the Med-techs confirmed that no MT had been scheduled to cover the AL unit for the morning shift on 1/25/26. Med-techs reported that an MT from the Memory Care Unit (MCU) was eventually called to assist with AL medication administration; however, by the time coverage was arranged, there was insufficient time to administer medications to one resident due to the proximity of the afternoon medication schedule. LPA interviewed eight (8) out of sixty-seven (67) residents regarding their medication experience on 1/25/26. Two (2) out of eight (8) residents, including R1, confirmed they did not receive their morning medications on 1/25/26. The remaining six out of eight residents reported having no issues with their medications and stated they had never missed a dose. LPA reviewed the staff schedule for 1/25/26 and verified that MT had been assigned to the AL morning shift, however the call out resulted in a lack of timely medication coverage. LPA also reviewed residents’ Medication Administration Records (MARs) for that date and confirmed that R1’s morning medications were not initialed or documented as administered. Additionally, LPA reviewed the unusual incident report submitted to CCLD on 1/29/26, which documented the missed medication. Continue on LIC9099-C Throughout the investigation, LPA evaluated the facility’s medication procedures, staffing practices, and documentation protocols. LPA also discussed medication administration expectations with facility staff. Based on interviews and record review, it was determined that the facility did not ensure R1 received their medication in a timely manner on 1/25/26 due to inadequate staffing coverage and delayed medication administration. Therefore, the allegation is SUBSTANTIATED. A deficiency issued during today's visit, see LIC9099-D Exit interview conducted, appeal rights explained, and a copy of this report signed and delivered.