complaint·December 10, 2025

Report Continued from LIC 9099... It was alleged that staff did not ensure resident took medication as prescribed. It was reported that Resident #1 (R1) did not take their medications for several weeks, which resulted in R1 being hospitalized. Additionally, when R1 moved out of the facility, medications were found scattered throughout their apartment. The LPA conducted a medication review on 11/20/2025 and observed three (3) randomly selected residents centrally stored medications. Medication review revealed that medications were being properly documented on the Centrally Stored Medications and Destruction Record (CSMDR). The LPA and staff conducted a pill count, and the quantities matched the documentation. Staff also noted when residents did not take their medications as prescribed due to being away from the facility or refusing to take them. Interviews with staff revealed that they had not experienced any problems with R1 refusing medications or administering their prescribed medications. Staff stated that R1 understood the importance of taking their medications as prescribed. Staff explained that during medication administration, they provide residents with a cup of water and wait for the resident to take the medication and return the empty cup. Staff also stated that they have not had issues with residents hiding medications instead of taking them. Further interviews revealed that staff are familiar with residents who refuse medications or have difficulty taking them, and they stated that R1 was not one of those residents. Staff added that R1 was adamant about receiving their medications on time and that they had no concerns regarding R1’s medications. Staff also reported that R1’s family had never expressed any concerns. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure resident took medication as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.