Complaint·July 24, 2025

Continued from 9099... This is an amended report from 07/24/2025. LPA discovered through interviews that due to a supply issue the Licensee was unable to obtain medications through the VA and used another pharmacy which was authorized by R1's responsible party signing a Pharmacy Agreement on 06/22/2023. LPA found the Licensee paid the responsible party $961.63 for the costs incurred as a courtesy. Based on the signed Pharmacy Agreement the allegation that resident’s personal rights were violated is unsubstantiated. Continued from 9099A A review of the Electronic Medication Administration Record (EMAR) shows that it was updated by facility staff (S1) and verified by (S2) on the same day to reflect the change. Electronic Medication Administration Records (EMAR) indicate that the medication Mirtazapine was discontinued on June 27, 2024, by VA (Veterans Administration) staff. On September 7, 2024 (R1) received a new order re-starting Mirtazapine (same dosage) by their physician, not with the VA. EMAR records show medication being administered the same day as order received. On December 27, 2024, R1 received a new order for Mirtazapine under a new physician’s order, which is indicated in the EMAR. In addition, the complainant stated that R1 received an additional flu vaccine after receiving one from a care provider. Facility was provided a standing order signed by a physician for a yearly flu vaccine. Staff (S3) stated that a call to responsible party approved the administration of the vaccine. R1 received the flu shot on November 25, 2024, at 10 AM based on the medical information they had. It was not until later, upon receiving a bill for the vaccine that it was discovered that R1 had already received a vaccine from their care team prior to the November 25, 2024 vaccine, however that information had not been given to the facility. Based on medical, pharmacy and medication administration records, the allegation that the Licensee did not follow physician’s orders is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.