Complaint Investigation Report

Interviews with staff members S1, S2, S3, S4, and S5 indicated that they have not witnessed residents' medications being mismanaged at the facility. Administrator Jasmin stated that R1 received a prescription of five (5) mg Melatonin with a doctor's order stating as needed as a PRN sometime in September 2023. Administrator Jasmin stated that medication was corrected to a ten (10) mg routine medication after being refilled. LPA observed R1's Physician Order Sheet dated June 29, 2023 which shows that Melatonin was prescribed to R1 as a ten (10) mg routine medication. Administrator stated that five (5) mg Melatonin for R1 was destroyed at a pharmacy and signed off by a pharmacy. LPA observed R1's Centrally Stored Medication Form (CSM) which showed that five (5) mg Melatonin was administered one (1) tab a day until prescription was refilled, in which five (5) mg medication was destroyed. Records do not indicated that more than one (1) tab of Melatonin was administered.

On December 19, 2024, LPA arrived at the facility and conducted a medication count for R1, comparing the resident’s CSM and Medication Administration Record (MAR) with medications centrally stored for the resident. LPA observed emptied bubble packs stored since September 2024 with dates in which each tab was administered for R1. LPA observed no medications were refused. LPA observed medications given as prescribed. On March 14, 2025, LPA arrived at the facility and conducted a medication count for residents R1, R2, and R3, comparing each resident’s CSM and MAR with medications centrally stored for the resident. LPA was joined by Local Long-Term Care Ombudsman (LTCO) during medication count. For R1, LPA & LTCO observed emptied bubble packs stored since September 2024 with dates in which each tab was administered. LPA & LTCO observed no medications were refused and observed medications given as prescribed. LPA did not observe any errors when comparing medication count with CSMs for R2 and R3. LTCO confirmed LPA's findings regarding medication count during visit.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.