complaint·February 27, 2025

S1 stated that the prior Resident Service Director had shredded R1’s Centrally Stored Medication Records (CSMR) and could not produce those records as requested by LPA Jeffries. S1 did have Medication Administration Records (MAR) for R1 and were reviewed by S1, Facility Administrator, Carl Meyer, and LPA that shows which medications were administered as prescribed. On 01/30/2025, Facility Administrator and LPA conducted a documented medication audit comparing Medication Prescriptions, Medication Invoices, MAR dates and times and the physical medications that were returned to F1 upon R1’s exit of the facility. That Medication and Document audit showed that for medication 1(Md1) there were 450 total pills sent to the facility, and 18 were returned to F1 indicating that there were approximately 30 pills over the number of MARs indicated. For medication 2 (Md2), there were 450 pills provide to the facility with 106 pills returned to F1, indicating 344 MAR as indicated which is approximately 54 pills of medication there were not administered despite MAR indicating those pills were administered to R1 on facility MAR. There were 540 pills of medication 3 (Md3) that were provided to the facility, and 176 were returned to F1, indicating 346 MARs indicated, which is approximately 56 pills that were not administered when MAR indicated they were administered to R1. There were 540 pills of medication 4 (Md4) provided to the facility, and 245 were returned to F1 indicating there were approximately 103 pills that were not administered to R1. There were 450 pills of medication 5 (Md5) that were sent to the facility, and 365 pills returned to F1, which is approximately 83 pills that were not administered to R1. LPA noted that on 01/29/2025 and 01/31/2025 physical medication counts were conducted with no discrepancy in count of the numbers of pills returned to F1, before and prior to the full medication audit to ensure accuracy. At this time there is enough evidence to support the allegation of, “Staff did not administer residents’ medication.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.