Complaint·November 26, 2025

It was alleged that staff did not ensure resident's medication was provided, the investigation into the above allegation consisted of interviews and record reviews. LPA conducted an interview with staff S1-S3. Record review reveal that R3 is prescribed psychotropic medications due to their mental health; Invega Sistenna (234 mg/1.5 ml) is prescribed to be injected intramuscularly every 28 days. S3 stated there was a delay on the pharmacy delivering the medications to the facility. Daily notes indicate S3 contacted the pharmacy the week of 10/27 and 11/5/25 in regard to requesting the medication for R3 be delivered. S3 stated R3 was supposed to get the shot on 11/3/25, however they did not received the Invega shot until 11/7/25.S3 stated they forgot to log it on the Medication Administration Record (MAR) and there is no record that R3 received the injection in November 2025. Per S3, R3 has not missed the injection in the past, aside from the month of June where there was a delay in medication, in which R3 refused the injection on 6/16/25 and it was given on 6/17/25. Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure resident's medication was provided, is substantiated. As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.