Complaint·May 15, 2025

LPA reviewed training records for two (2) staff who administer medications and observed ten (10) hours of medication training upon hire, one (1) hour of hands-on medication orientations conducted monthly, and two (2) hours of medication management conducted by Administrator. Training was in the format of videos, tests/quizzes, and shadowing. All staff handling medications are training certified by Administrator and Licensed Vocational Nurse (LVN) Kim Anderson. Staff are qualified to administer prescription medications, as-needed (PRN) medications, over-the-counter medications, controlled medications, and assist with self-administered medications. Staff interviews confirmed that staff are knowledgeable in medication administration and management. No concerns were noted. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Unqualified staff are administering medications to residents in care” is deemed UNSUBSTANTIATED at this time. It was further alleged that Staff #1 (S1) administered nonprescription melatonin to Resident #1 (R1) without physician’s or responsible party(ies)’ order/approval. Staff interviewed during the initial visit and today’s visit had no evidence supporting the allegation. LPA reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Record (MAR) for R1 and another resident and observed no documentation of melatonin administration. Medications were centrally stored and locked in the kitchen. All medications and PRNs had physicians’ order on file and PRN authorization letters. Medications were prepared for one (1) day in advance and were properly documented on the CSMDR and MAR. No errors were observed during the medication review. LPA observed that R1 had two (2) prescription medications of Lorazepam 1 mg and Divalproex Sodium 125 mg. Administrator stated that R1 is not administered melatonin as there is no physician’s order and no need because of their prescribed sleep aids. Administrator stated that there is one (1) resident who takes over-the-counter melatonin, and there is physician’s approval. LPA did not observe melatonin stored with R1’s medications. Based on interviews, record review, and medication review the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff are administering medication(s) to resident without physician's approval” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.