Complaint Investigation Report

Allegation: Facility did not administer residents’ medications in a timely manner

On 02/12/26 at 3PM, LPA interviewed staff (ALD, Director of Nursing, S1) who stated that residents’ (R1, R2) medications were not administered in a timely manner because of S1’s failure to prioritize timely medication administration to residents on 02/01/26 because of two emergencies that happened around 10:30AM. S1 stated the other Med Tech on duty was busy helping other residents with their medications and could not assist her. Review of email documents dated 09/30/25, 10/02/25, 01/20/26 and 02/01/26 showed staff failed to administer R1 and R2’s medications in a timely manner and R1 had to call staff to give R2’s medications. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility did not administer residents’ medications in a timely manner is substantiated.

Allegation: Facility missed resident’s blood pressure checks

During investigation, LPA interviewed reporting party (RP) and staff (ED, ASL Director, S1). RP stated that R2’s twice daily blood pressure checks (one in the AM and another in the PM) were not being done by staff. ALD stated staff failed to perform R2’s blood pressure checks daily due to a lack of better training to fulfill residents’ care requirements. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility missed resident’s blood pressure checks is substantiated.