Complaint Investigation Report

During today's visit, LPA obtained the following documents: R1’s Physician’s Orders, Doctor’s Prescription Request, and Medication Administration Records (September 2024, October 2024, November 2024). LPA did not observe any health and safety concerns. LPA interviewed R1, Witness #1 (W1) and the Administrator.

Allegation: Staff did not dispense medications as prescribed. It is alleged that the facility staff are not providing medications correctly which has caused R1 to be taken to the hospital frequently. No other details are provided. During initial visit, LPA reviewed a random sample of medications of five (5) residents and all medications are given as prescribed. During the initial visit, LPA interviewed six (6) out of six (6) staff and they all denied the allegation. During the initial visit, LPA interviewed nine (9) out of nine (9) residents and they all claim to receive all medication as prescribed from the staff. During today's visit, LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record (September, October, November 2024), all medications are given as prescribed. LPA also interviewed R1 and R1 stated that medications are received to R1 as prescribed. There is not enough evidence to substantiate.

Allegation: Staff neglect resulted in resident falling. It is alleged that the staff have continued to provide R1 with the incorrect medication resulting in R1 falling and being incoherent. No other details are provided. During the initial visit, LPA interviewed six (6) out of six (6) staff and they all denied the allegations and nine (9) of nine (9) residents all said they have not experienced nor witnessed any falls due to staff neglect. During today's visit, based on interview, R1 stated that R1 fell due to "dazing off" and did not allege the falls were due to staff neglect. R1 stated that the physician believe it may be due to one medication so R1's physician discontinued the one medication in September 2024. During R1's three years of residence, R1 has only experienced falling three times. LPA reviewed Special Incident Reports of R1's the three falls which occurred once in August 2024 and twice September 2024. For all three falls, R1 was taken to the hospital suffered no fractures an d was treated for minor injuries. No falls from R1 have been reported ever since the fall in September 2024. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of eviden ce to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held with the Administrator, Gill Agas and a copy of this report was provided.