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32 | From 9:12 AM to 10:00 AM, LPA interviewed the administrator and reviewed and obtained documentation, including but not limited to: residents' Physician’s Reports, Pre Admission Appraisals, Appraisal/Needs and Services Plans, R1's Centrally Stored Medication Administration Records, and R1's hospice documentation. At approximately 11:18 AM LPA Rios interviewed one (1) other staff member.
The investigation revealed the following:
Allegation: Staff crushed residents' medication without consent. Regarding the allegation, it is reported that staff crushed residents’ medications and mixed them into their food prior to serving, without the residents’ knowledge.
Interview with R2, revealed they do not receive staff assistance with medication administration. According to R2, they store and take their medication without staff assistance. LPA’s review of R2's Physician's Report dated 12/31/2025 confirms that R2 is able to manage and store their own medication and is also able to self administer their own medication. R2 confirms they have witnessed staff crush medication for R1 in the facility and place crushed medication into R1's pudding. According to R2 they have lived at this facility for about a month and this was also done at the previous facility where R1 and R2 were residing. Interview with the administrator and staff revealed they are crushing R1's medication and mixing it into soft foods. According to the administrator they are following a medication protocol continued from the previous facility and confirmed medication administration with R2's Hospice agency. The administrator also stated R2 is always told when the medication is being provided. LPA's review of R1's Physician's report dated 04/16/2026 revealed R1 is unable to administer own medication. Review of hospice documentation revealed their is physician's order in place indicating it is "ok to crush Prescription Ordered (PO) medication". Hospice documentation also noted R1 is on a puree diet.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
No deficiencies cited. Exit interview conducted. Copy of this report provided to the administrator. |