It is alleged that staff did not follow residents’ prescription orders. Regarding this allegation it is reported that on 09/14/25 staff gave Client #1 (C1) a whole pill of pain medication for back pain when the prescription called for half a pill. Interview with Administrator revealed that the pain medication that was prescribed to C1 was in fact for half a pill, however CVS pharmacy did not cut the pills prior to dispensing them. Administrator stated that this was informed to C1 and explained that facility staff are not to alter any medication so in the interim C1 was given their PRN pain medication, which is prescribed as a whole pill, while CVS cut the new pills for them. Administrator states that this information was shared and explained to C1 and that C1 stated that they understood. Once CVS returned the cut pills to the facility, the staff then let C1 know that they could now issue the half pills. LPA interviewed House Manager (HM) who confirmed the information that the Administrator shared. LPA also interviewed Staff #1 (S1), who corroborated what Administrator stated, adding that they are all aware that medication cannot be altered by staff and that PRN on file allows for C1 to ask for pain medication when needed. LPA interviewed C1 via cellphone and C1 revealed that this was a misunderstanding on C1’s part as C1 believed that they were receiving a whole pill of the pain killer when the prescription called for a half pill. C1 states that they did not know that the half pill is a different medication than C1’s PRN medication but is aware that both medications are for pain and are aware that the PRN medication is a whole pill. Furthermore, C1 stated that HM explained the situation and C1 understood that they were given the correct dose at all times. LPA reviewed medication logs, counted medication for accuracy and reviewed prescriptions, and all documentation supports what was stated by Administrator and staff, therefore based on observations, record reviews and interviews, this allegation is deemed unsubstantiated.

Continued on LIC9099-C

It is alleged that staff did not provide transportation for a resident. Regarding this allegation it is reported that Client #1 (C1) was not feeling well while attending day program and that when day program staff contacted the facility to have staff pick up C1, the facility staff refused. It is reported that staff refused to pick up C1 because it was close to dismissal time. It was also reported that staff were unable to accommodate the request due to shift change and not having staff available to pick up C1. LPA interviewed Administrator who denied that staff refused to pick up C1 and denied that transportation was not provided for C1. Administrator stated that day program staff does not and has not communicated with facility staff when C1 needs to be picked up, all communication has always been directly with C1. C1 will text or call facility staff to let them know that program will be dropping C1 off early, but that program staff does not clearly communicate with facility staff. Administrator and House Manager (HM) both stated that this is an ongoing situation with the day program in which C1 is continuously dropped off early, but that at no time is program staff alerting facility staff that C1 needs to be picked up. Administrator, HM and S1 state that there is always someone home to either pick up clients or be present for clients to be dropped off. Interview with Staff #1 (S1) corroborated the same information provided by Administrator and HM, stating that C1 has not asked to get picked up but alerts staff that they will be dropped off by day program. LPA interviewed C1 via cellphone who stated that they have no concerns about transportation and that staff always accommodate C1 when C1 has a need to be dropped off early from day program. C1 also stated that they do not have any concerns when they have to wait for the facility staff in case, they are not at the facility due to taking other clients to other appointments. Therefore, based on observations and interviews this allegation is deemed unsubstantiated.

No citations issued. Exit interview conducted and copy of report provided.