complaint·May 28, 2025

Staff are not ensuring that resident is administered their medications according to physician's instructions. LPA conducted a review of Resident R1’s medication against the Medication List that was provided by home health. LPA observed that R1’s medication list and Medication Administration Record (MAR) do not match and there are medications missing from the medication list that R1 is being given and medications that R1 is prescribed that the facility does not have for R1. During initial investigation on 05/15/2025, LPA requested a medication list for R1’s medications that were being given. Facility could not provide a medication list or Centrally Stored Medication Record (CSMR) to LPA. LPA received medication list from Home health nurse who arrived while LPA was conducting the visit on 05/15/2025. Interviews with home health nurses that are visiting R1 indicated that their first visit on 05/07/2025, the nurse attempted to review R1’s medications but there were no medications present at the facility for R1. Home health nurse came for a second visit and after their assessment, sent R1 to the hospital due to high blood pressure readings since no medication was being given for blood pressure even though R1 had a current prescription for blood pressure medication. The allegation staff are not ensuring that resident is administered their medications according to physician's instructions is substantiated. Staff are mismanaging resident's medications. LPA conducted a review of Resident R1’s medication record. The review of R1’s medications indicated that R1 has five medications on their medication list that are not being given or are not being given as prescribed. During investigation, LPA requested a Centrally Stored Medication Record (CSMR) for R1 but the facility did not have a CSMR for R1. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Administrator and a copy of the report and appeal rights was provided.