complaint·September 22, 2025

Staff mismanaged resident's medication. It was alleged that the facility did give Resident #1 (R1) insulin for three (3) days. To investigate this allegation LPA conducted an interview with the Administrator who denied the allegation and informed LPA that they always provide medication to all the residents in a timely manner without any discrepancy. However, review of R1's Centrally Stored Medication Record (CSMR) revealed that eleven (11) out of eleven (11) prescribed medications have discrepancies and were not provided as prescribed. Furthermore, review of R1's hospital records revealed that R1 was hospitalized from 09/11/2025 through 09/13/2025 due to dizziness for not taking his/her insulin for three (3) days. Additionally, the medical records also revealed that R1 experienced sweating, thirstiness, and polydipsia. LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. Therefore, based on the medication record review, medical records, and interviews this allegation is Substantiated. Resident did not receive medications as prescribed. It was alleged that the facility did not have R1's medication at the facility. To investigate this allegation LPA conducted an interview with the Administrator and S1 and both parties interviewed confirmed that R1 currently does not have eight (8) out of eleven (11) prescribed medications due to R1's medical insurance issue. Furthermore, LPA was informed that three (3) out of eleven prescribed medication were also out as of 09/10/2025; however, upon R1's hospitalization R1 was provided three prescribed medication (Divalproex, Lisinopril, and Insuline Aspart) at the hospital. Additionally, LPA reviewed R1's CSMR, and the above information was confirmed that R1's medication run out and the Administrator was unable to refill. Based on interviews and R1's medication review, this allegation is Substantiated. Deficiencies issued and appeal rights explained. Exit interview conducted. Copy of this report signed and delivered.