complaint·October 23, 2025

Per the incident report dated August 4, 2025, R1 was admitted to the hospital per the nurse’s advice on July 28, 2025. The American Heart Association indicates that warfarin is a prescription medication used to prevent blood clots. Warfarin is adjusted based on the results of the blood test, International Normalized Ratio (INR). A normal INR range is between 2 and 3.5 when taking blood thinners. However, R1’s INR levels was an 8 and increased to 12 upon hospital admission which is considered high. Based on the interviews, four out of four staff denied the allegation indicating that R1’s medications were administered appropriately. For R1’s warfarin, the Veterans Affair (VA) Inquiry Sheet dated November 5, 2024, indicates that one tablet is given every evening. In review of the Medication Administration Records (MARs) for June and July 2025, R1 did not receive warfarin on June 16, 19, 21, and 23. One out of the four staff indicated that medication was not given due to R1’s refusal. R1 did not recall why the warfarin was refused at the time of the interview. Three out of the four staff denied tampering R1’s food and water with warfarin and had only administered the medication at the request of R1 which was instructed and relayed by R1’s nurse. The remaining one staff was not assigned to administer medication at this facility and could not provide further information. During the initial visit conducted on August 4, 2025, LPA observed all medications were secured in the medication closet. There were no medication errors observed in review of four out of four residents. Two out of the four residents reported having no issues with their medications. LPA was unable to qualify the remaining two residents due to their medical diagnosis. The investigation revealed that there was insufficient corroborating evidence to prove staff were tampering with R1’s food and water. The Physician’s Report dated January 22, 2025, indicated that R1 did not have a food allergy or a special diet prescribed by the doctor. There was no order suggesting removing garlic from R1’s diet. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, 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 following allegation: Facility is not administering medication as prescribed is deemed UNSUBSTANTIATED. An exit interview was conducted with Lead Caregiver Rosmie Morata, and a copy of this report was provided at exit.