Complaint·June 25, 2025

W1 stated that they contacted Administrator Lisa Gerr who stated that the medication Olanzapine was not delivered to her facility until after R1's discharge on 05/01/25. W1 stated that they have receipt from Federal Drug Company that shows all medications were delivered to the facility on 04/22/25. W1 stated that the missing medication was eventually provided to R1's new facility Administrator on 05/19/2025. On 06/25/25 LPA Jeffries conducted an interview with Administrator Lisa Gerr, who stated, "..on (05/01/2025) R1 returned to the facility after normal business hours requesting all medications for 1 week. Administrator provided all medications from R1's medication storage bin with custody receipt provided and singed. Administrator stated that medication in question was placed in S1 desk drawer and was discovered at unknown later date and was delivered to new facility with custody receipt 05/19/25.On 06/24/25, LPA reviewed documentation from Federal Drug Company, Drug Order Delivery Form, which indicated that a total of 6 medications, including (Olanzapine 2.5mg, Quantity 30) were delivered to this facility on 04/22/25, singed and dated by facility Staff 1 (S1). This delivery form establishes the custody of R1's medications were in the care of this facility starting on 04/22/25. On 05/01/25 all other medications, with the exception of Olanzapine 2.5mg, were provided to W1 by the Administrator, Lisa Gerr, due to R1 permenatly leaving as a resident on the evening of 05/01/25. On 06/25/25, LPA Jeffries received an email from Robert Glock, Administrator of Rt 1's current facility stating that on 05/19/25 Lisa Gerr dropped of R1's personal items that included the Olanzapine 2.5mg medication. Due to the facility having documented custody of the Olanzapine medication on 04/22/25, and on 05/01/25 Administrator, Lisa Gerr provided W1 with R1s medications, excluding the Olanzapine, Based on documentation, and interviews, there is enough evidence to support the allegation of, "Staff are mismanaging residents medications." and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.