complaint·September 30, 2025

Staff are mismanaging residents’ medication - UNSUBSTANTIATED It was reported that Resident 1 (R1) received a diagnosis on 08/19/2025 and a medication was prescribed the same day at 4:56 PM. As of 08/20/2025 4:00 PM the medication had not been picked up because the facility stated they needed a physician’s order first. LPA reviewed R1’s care plan which states that R1 independently manages their own medications. R1’s LIC602 Physician’s Report states that R1 can manage their own treatment, medication, and equipment, is able to administer and store their own prescription medications. LPA reviewed a prescription from R1’s physician which was sent to the pharmacy at 04:57 PM on 08/19/2025. LPA reviewed a written prescription from R1’s physician dated 08/20/2025. There is a handwritten note “clarified order 08/21” on both. Executive Director stated that R1 went to appointment late in the day on 8/19/2025 during which their physician prescribed two medications and called in the prescriptions to a local pharmacy and the facility was not notified by the doctor’s office or the pharmacy. On 08/20/2025 the facility called R1’s doctor’s office three times because they had not received any orders from the appointment and did not receive a return call. That day the pharmacy called and stated they were waiting for clarification from R1’s doctor on one medication. Later that day the pharmacy called and informed they had received the required clarification from R1’s doctor on the order but it was past their delivery time and they could not deliver until the following afternoon. One of the facility directors went to the pharmacy and picked up the medications and brought them back to the community. The facility was advised by the pharmacist to not start the medication until the following morning. R1 started both medications on 8/21/2025. Typically, R1 manages their own medications, but was confused and apprehensive on the required taper, so the facility assisted. It was determined that the facility dispensed R1’s medication to them as directed by the pharmacist. The medications were delayed as a result of the physician’s office not communicating efficiently with the pharmacy and facility. This was out of the control of the facility. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Executive Director Nicole Braswell and Rosanna Larsen- Burrill - Business Services Director.