complaint·March 26, 2026

The investigation revealed the following: Regarding the allegation: " Staff do not ensure prescribed medications are properly managed or dispensed." It was alleged that staff do not dispense all of R1's medications and the pain medication is consistently missing. (2) out of (6) staff interviewed co rroborated the allegation. Staff stated that they observed many medication errors on their shifts and many residents are aware that they were not getting all of their medications. (2) staff also stated that they have seen other staff pre-pour all the medication the night before, as directed and postpone giving it to the residents. When it's too late, staff would simply throw away the medication, causing the residents to miss their scheduled medication regimen. (2) of (6) residents interviewed stated that the staff had either forgotten to administer their medications on time or had failed to administer their medications at all . LPA observed a number of medication errors for (4) different residents including R1. Additionally, a review of R1's medication administration records revealed that procedures were not followed and there was insufficient supervision. Therefore, there was sufficient evidence to corroborate with the allegation. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency cited on the attached LIC 9099D. A civil penalty assessment (LIC421M) was also issued for repeat violations. An exit interview was conducted, and a copy of this report provided to Maria Quizon, Executive Director along with the Appeal Rights. The investigation revealed the following: Regarding the allegation: "Staff does not ensure issues of missing medications is being properly addressed." It was alleged that R1 has been consistently missing a prescribed medication and facility's pharmacy has regularly failed to fulfill R1 's prescription in a timely manner. Staff interviewed stated that R1 did not have missing medications but has a PRN prescription that cannot be filled early without a doctor's intervention. R1 has a PRN prescription for (120) pills, supposedly good for (4) months. However, the pills only lasted for thirty days because R1 took the medication four times daily . Because it is a controlled substance and not on cycle, it needed doctors authorization. When staff contacted the pharmacy to follow up, the pharmacy claimed they have not received the authorization from R1's doctor yet. Staff stated that their method in requesting refills for medication from PAX pharmacy is either via fax, phone or online and the pharmacy is quick with response time and completing orders. Interviewed residents stated that they have not missed medications and they get refills on time. Documents reviewed showed that staff have followed the method for refilling the medication but there may have been a breakdown in communication between the physician and/or the pharmacy. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Maria Quizon, Executive Director.