complaint·March 10, 2026

9099C-1.. Allegation: Staff are overdosing resident. The allegation states that resident (R1) moved in with a supply of Oxycodone consisting of a bubble pack of (5) pills and a bottle of (20) pills. When (R1) moved out after (10) days or residence, there were (15) pills missing. (R1) was observed to be knocked out and asleep every day when visited almost everyday. The family member stated she moved (R1) into the facility on December 1, 2025 (1:25 pm), due to having a broken hip, and (R1) was prescribed Oxycodone 5 mg, as needed, but hadn’t taken it since November 18, 2025. The family member stated she specifically told the facility not to administer Oxycodone since (R1) moved in with their other medications, which included Tylenol 325 mg, as needed. The family member stated that when she counted (R1’s) Oxycodone on December 15, 2025, there were (15) pills less than when (R1) moved in, (R1) was only there for (10) days, excluding hospital days, and confirmed (R1) moved in with a bubble pack of (5) pills, and a bottle with (20) pills was provided the following day, December 2, 2025. Both the Administrator and Administrator Designee stated (R1’s) medications were counted when they moved in but were not sure the medications were counted when (R1) moved out. Both stated that additional Oxycodone pills were brought over after (R1) moved in. Documentation shows (5) Oxycodone pills were initially logged and then another (20) Oxycodone pills were logged on a separate page, as being administered, starting on December 11, 2025. Both administrators confirmed Oxycodone was given twice daily (morning and evening) after (R1) returned from the hospital on December 11, 2025; however, MAR documentation shows Oxycodone was given twice daily, at 8:00 am and 8:00 pm, from December 1 to December 5, 2025 and from December 11 to December 12, 2025, refused in the evening from December 13 to 14, 2025, and received it in the morning on December 15, 2025, before moving out. The MAR notes (R1) was hospitalized from December 6- 10, 2025. The Administrator indicated (R1) was receiving Oxycodone on an “as needed” basis before moving in, and it would make (R1) "sleepy and (R1) was receiving the same dosage" prior to moving to the facility. The prescription provided by the skilled nursing facility was for Oxycodone 5mg states "1 tablet every 6 hours, as needed for moderate or severe pain" with additional instructions to try at least one alternative intervention (positioning, back rubs, visualization/deep breathing exercises, and distraction) prior to administering PRN Oxycodone, and to document the number of interventions attempted. *cont on 9099C-2.. 9099C-2.. LPA reviewed medication orders for all of (R1's) medications and the MAR reflected medications were given as ordered. PRN Tylenol was also given three times daily for pain from December 1 to December 5, 2025 and from December 11 to December 14, 2025 . LPA reviewed the MAR for another resident (R2), who had moved in December 21, 2025, and observed all medications were logged and initial counts were noted, as with (R1’s) medications. The family member indicated she visited (R1) daily and at different times of the day, but the most common time was 1:00 pm, and (R1) was "always sleeping" at that time. The family member stated she asked the doctor to discontinue Oxycodone on December 14, 2025, after (R1) returned from the hospital. The MAR shows (R1) was taking multiple scheduled medications, including Depakote, twice daily, which had a side effect of drowsiness. The administrator stated he assessed (R1) in a hospital and skilled nursing setting, prior to moving in, and (R1) was very lethargic and not able to communicate well. The Administrator Designee stated during the pre-appraisal, the facility was told (R1) was not aggressive and would only “lift their hand”; however, (R1) tried to hit the family member at least once. The Administrator Designee stated he gave (R1) Oxycodone for delirium, and (R1) indicated they had pain when asked, although they were difficult to understand, commenting that if (R1) started to have non-verbal communication, such as being aggressive, he would wait (30) minutes and then try to offer the care again. The family member stated (R1) was taken to the Emergency Room on December 6, 2025 for constipation and returned to the facility on December 11, 2025. On December 13, 2025, the administrator stated that (R1) was not wanting to wake up or drink water and should be evaluated for hospice. Both administrators and the family member stated that (R1) would eat well but regularly refuse hydration. The administrator stated to LPA that this change was due to (R1's) "worsening of existing "generalized weakness"" and not due to the facility administering too much Oxycodone. The administrator stated (R1) would indicate they were experiencing pain in the morning and evening, so that is when Oxycodone was administered. Additionally the hospital discharge paperwork (December 11, 2025) gave instructions to keep Oxycodone "at minimum" (two times per day as opposed to every 6 hours) since Divalproex/Depakote was already calming (R1). The administrator stated that (R1)'s primary care provider recommended Palliative Care due to his condition being terminal, which was the main reason why (R1) often refused hydration and became constipated. LPA observed a discrepancy in what the administrators stated (R1) was administered and what the MAR documentation shows for the medication, Oxycodone 5mg. Based on the initial count (25) of the Oxycodone medication and (10) pills that were returned, (15) pills were administered over (10) days, which is significantly less than what the prescription allowed for -up to (4) pills administered daily, (1) every (6) hours. Based on information obtained, the allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.