Complaint Investigation Report

LPA Urena interviewed staff and residents from approximately 10:30 a.m. to 12:26 p.m. and requested records pertinent to the investigation. At 2:35 p.m. the Licensee arrived at the facility, and the LPA interviewed the Licensee at approximately 2:40 p.m.

Staff did not administer medication to a resident in care. On the allegation that staff did not administer medication to a resident in care, it is the concern of the reporting party that the resident (R1) is not receiving their medication as prescribed. The LPA was unable to communicate with the RP for further information. To investigate the allegation at approximately 1:22 p.m. the LPA conducted a medication audit and interviewed residents. One resident stated they get their medication on time, one resident stated that they do not take medications. The medication audit consisted of reviewing the LIC 622 (Centrally Stored Medication and Destruction Record) and auditing prescription bottles/counting pills. The record review of the LIC 622 for R1 revealed that medications are not being recorded as they are received by the facility and discrepancies were found on dates (filled/ start date/ expiration date) between the LIC 622 and the medication bottles. One medication bottle for Atorvastatin (40mg./100 pills, 1Xd) with a count of 21 pills left in the bottle, showed that the medication bottle was filled on 08/21/2025 per the prescription label, however the LIC 622 stated the medication was filled on 03/27/2025. At the time of the medication audit the medication should have been refilled. It is unknown when the first day of the medication was given as the dates on the LIC 622 could not be confirmed. The second medication audited was Hydralazine (25m./90 pills/3xd) which was not registered in LIC 622. The interview with staff revealed that they assist two residents with insulin injections, furthermore, staff stated that they do give the medications to the other residents as prescribed. However, due to the medications not being properly documented in the LIC 622, it’s impossible to assess if residents have been properly assisted with their prescribed medications. The Licensee’s interview revealed that they could not explain the medication discrepancies.

Based on observation of the medication audit, and the interviews, the Staff did not administer medication to a resident in care as prescribed. Therefore, the allegation is deemed Substantiated at this time.