complaint·July 22, 2025

(Continued from LIC 9099) An Unusual Incident Report was received by the Regional Office on Monday, July 14, 2025 regarding the medication error. Per Unusual Incident Report, "R2 was placed under close monitoring protocol, with vitals assessed regularly throughout the evening and overnight. No adverse effects were observed." It is noted that R2 remained stable, alert and could communicate needs. A Nurse Practitioner visited R2 the next morning and resident remained stable and at baseline. Therefore, the allegation that staff are not following reporting requirements is Unsubstantiated. LPA reviewed R1,R2 and Resident #3 (R3)'s electronic Medication Administration Records and reviewed resident files. LPA also audited the med cart for all three residents and meds were on cycle, and eMARs were properly initialed. For the resident, R2, who received the wrong medication, it was documented by the nurse, "DNG" which stands for Did Not Give for PM meds. LPA spoke with Nurse regarding medication destruction procedures and meds are destroyed within 24 hours, if not given. Thus there were no extra medications in the med cart for R2. The allegation that staff falsified residents' records is Unsubstantiated. LPA interviewed Residents #1 and Resident #2 while conducting a health and safety check. LPA also interviewed one witness and five of five staff members regarding the incident on the evening of July 13, 2025. Although the allegations may have happened or are valid there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations: Staff are not following reporting requirements and Staff falsified residents' medication records are Unsubstantiated. An exit interview was conducted with Ashiman Gill, Administrator and a copy of this report was provided to the facility.