Complaint Investigation Report

9099C-1.. Allegation: Medication is being mishandled by staff. The allegation states than a Med Tech on the "am" shift has been observed to walk away from the medication cart, without securing it and to leave medications for residents in their rooms without ensuring they are immediately taken. Additionally, loose medications have been found in resident wheelchairs, in beds and on the floor.

One Med-Tech explained that the procedure for administering resident medication is to "check the resident's chart, look at the board in the Med Room and check the MAR (Medication Administration Record) if there are any antibiotics to be administered. This Med-Tech explained she looks at each resident's names before administering the meds and confirmed residents "will refuse sometimes and we will try 3-4 times", confirming the meds stay in the cup and she will put the cup back in the medication cart if the resident refuses. The Med-Tech confirmed that staff are not trained to leave medications with residents, asserting, "No, we can't leave medications with residents".

A second Med-Tech (pm) stated she "makes sure meds are taken by the resident, residents usually takes meds willingly", and pre-poured meds are in "cups that are in a little case that is locked". A caregiver was asked if Med-Techs will leave the medication cup with pills in the resident's room and go to the next resident's room and replied, "Yes, they leave the whole cart and laptop open"- you can see resident's profile and medications they take. The staff added, "sometimes the Med-Tech will ask a non-Med-Tech, or a caregiver to walk the medications to a resident's room, and this usually occurs on the "am" shift. Another caregiver stated she found a paper cup with a red pill in it in Hallway A and gave it to the DON on October 16, 2025.

LPA and their manager spoke to (2) residents in the Assisted Living Unit on January 30, 2026. The residents were asked if Med-Techs leave the medications and then proceed to the next resident's room, or if the Med-Tech waits for them to take the medications. One resident responded "sometimes they leave the medications and go". A second resident stated " they leave the medications- they leave them for me at 8:00 am" and then "around 8:30/9:00 am, I take the medications myself".

LPA reviewed the Physician's Orders for these two residents. One resident takes the following scheduled medications at 8:00 am: Buspirone 10mg, Metformin 500 mg, Fluticasone Prop 50 mcg nasal spray

The second resident takes the following scheduled medications at 8:00 am: Aripiprazaole 5 mg, Oxybutynin Chloride 5 mg and Phenazopyridine HCL 40 mcg. *cont on 9099C-2..