complaint·April 9, 2025

The room has lighting and there is no kitchen as the unit is only 1 room. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff do not ensure medications are properly managed for residents in care, revealed the following. It was alleged that the facility does not properly manage residents medication including Resident 1 (R1) who allegedly ran out of their PRN medication (Acetaminophen 500 mg) on or around March 20, 2025. LPA reviewed 7 resident medications records for March and April 2025, including R1's records. LPA observed all medications are secured in the medication room in a medication cart which is kept locked. Medications only leave the medication room under staff supervision when they are being administered to residents. A review of review of records shows R1 did not receive their Acetaminophen 500 mg on March 5, 2025 and March 20, 2025. 4 out of 4 staff members interviewed reported that on those days R1 did not request the Acetaminophen 500 mg which is a PRN medication. R1 reported that they ran out of their PRN Acetaminophen 500 mg on or around March 20, 2025 and had to refill the prescription on their own. R1 did not report missing their medication any other days other than on or around March 20, 2025. 4 out of 4 staff interviewed reported that R1's PRN for Acetaminophen 500mg was recently reordered and they never ran out. A review of R1's records show that the prescription for Acetaminophen 500 mg was refilled on March 26, 2025 and the bottle was first opened on March 26, 2025. The Medication Administration Record (MAR) for R1 for March 2025 shows the only days that the PRN Acetaminophen 500 mg was not administered was March 5, 2025 and March 20, 2025. Since the prescription was filled on March 26, 2025 and there are no other discrepancies reported or noted in the records and R1 received Acetaminophen 500mg PRN each day from March 21 through March 31, R1 never ran out of medication as reported. No discrepancies were observed in 7 out of 7 resident medication records reviewed. LPA interviewed 6 residents. 6 out of 6 residents reported not having any issues with their medications. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided R1 reported the items are where they want. R1 has all of the required furnishings in the room, which R1 provided. The facility is not required to provide additional furniture for storage. There are no trip hazards in the room because there is a clear path to the sink, microwave oven, bathroom, bed, patio door and front door. R1 and the staff reported conflicting information. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.