Complaint·April 27, 2026

It was learned that R1 underwent back surgery on 11/05/2025 and returned to this facility on 11/07/2025. The resident, R1, was originally prescribed and taking their pain medications which were Pregablin and Tylenol at that time. It was learned that on 11/09/2025 a family member for R1 dropped off a new PRN medication, Hydrocodone, for pain management and provided a prescription and order for that medication at that time. However, this facility did not dispense the medication to the resident since there was not a signed order from the responsible licensed medical professional. This matter was later resolved that same day when the facility nurse contacted the pharmacy and discovered that this particular pharmacy had their licensed medical professionals digitally sign all of their orders. Since this order was completed electronically by the licensed medical professional there would not have been a signed paper copy to accompany the order at that time. The medication, Hydrocodone, was then administered to the resident, R1, as needed when R1 complained of any pain or discomfort. Based on a review of the forms and documents that were gathered during the course of this investigation, it was learned that the new pain medication, Hydrocodone, was prescribed and filled on 11/09/2025 when it was dropped off to this facility. This medication was only a PRN and was not to be dispensed on a daily basis but only when the resident, R1, expressed pain and discomfort. It was learned that from 11/09/2025 to when the resident got their staples removed from their back surgery on 11/19/2025, this medication was dispensed a total of 11 times to the resident. Each time this medication was dispensed it was noted and entered into the facility Medication Administration Record (MAR) and charting notes as well. It was learned that the daily tasks assigned to the facility staff were completed and signed off after the completion of each shift for care and supervision to the R1. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview