Complaint·May 22, 2025

(Continued from LIC9099 p.1) Resident interviews did not corroborate the allegation. One resident that was claimed to have been involved in a medication error stated they had no issues at the facility and that the medication administration was good. Attempts were made to interview the second resident noted to have suffered a medication error, but the resident was unable to be interviewed. Facility records were reviewed regarding the allegation. Facility training records for Medication Technicians (Med Techs) were consistent with the medication processes listed by the Med Techs during interview. No records were found to show that a medication error had occurred. Regarding the allegation, "Staff did not ensure that residents' medications are stored in its original container", Staff members consistently stated that they had not observed any staff pre-pour medications. Staff informed that Med Techs actively pour while administering medications, or prepare all medications at once then pass to residents, with the preparation time not exceeding more than 1 hour, per company policy. Staff informed that inconsistencies existed with specific staff regarding the interpretation of what pre-pouring was. The staff member accused of pre-pouring informed that the resident was right in front of them during the medication administration and they were the only resident that was being assisted at the time, there was no confusion with the cups and no pre-pouring occurred. Review of facility records showed substantial medication training consistent with staff statements regarding how medications were administered at the facility. The facility's medication training policy dated December 2023 stated, "Resident medications may only be poured for a single med pass at a time". LPA directly observed the medication procedures and medication carts during two unannounced facility visits. LPA did not observe any medication cups that had been prepared in advance, locked or unlocked, around the facility or in the medication cart drawers. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.