Complaint Investigation Report

Allegation: Staff dispensed medication that was not prescribed to resident.

It was alleged that the staff has been administering L-Tryptophan to R1 at night without physician’s order. To investigate this allegation, LPAs conducted an interview with the Administrator who confirmed that R1 is taking L-Tryptophan (2tab x bedtime). The Administrator stated that staff are required to dispense medications only according to the physician’s orders and to verify orders before administration. However, The Administrator acknowledged that no physician’s order was available for the medication that had been given to Resident (R1) nor was it recorded on Centrally Stored Medications and Destruction Record (CSMDR). The Administrator also confirmed that the centrally stored medication record had not been updated or completed properly for this medication. Staff interviewed also confirmed that medication was administered to R1, for almost six (6) months, without a valid and current physician’s order. Staff further confirmed that the medication was not documented in the CSMDR. However, it’s recorded on Medication Administration Record. Lastly, LPAs reviewed R1’s medication records, physician’s orders, and centrally stored medication logs. LPA did not observe a physician’s order for the medication in question. Additionally, LPA observed that the medication was not recorded in the Centrally Stored Medication and Destruction Record consistent with regulatory requirements. Photographs taken by LPA showing the missing entries in the centrally stored log and the absence of corresponding documentation in R1’s file. Therefore, based on interviews and LPAs record reviews this allegation is Substantiated.

Allegation: Staff are confining resident to room.

It was alleged that the staff installed a child safety cover on R1’s bathroom and bedroom doors to prevent R1 from eloping at night. To investigate this allegation, LPAs conducted an interview with the Administrator who denied instructing staff to confine any residents to their room. The Administrator also disclosed that R1 has diabetes and, for R1’s safety, staff placed a child-proof lock on R1’s bedroom door. When LPA requested R1’s care plan, physician’s orders, and any behavioral plan related to the use of the child-lock or to R1’s medical conditions, the Administrator was unable to provide any of these documents. LPA conducted review of facility records and did not observe an exception request being submitted to the Department. During the initial (12/08/25) visit and today’s visit (06/03/26) LPAs observed child-proof lock placed on R1’s bedroom door. Lastly, a credible witness, who visited this facility on 12/13/25, reported observing staff confining R1 to their room on several occasions. The witness stated they saw staff physically blocking the doorway and instructing R1 to remain inside. The witness provided consistent, detailed information supporting the allegation. Therefore, based on interviews and LPAs/credible witness’ observations this allegation is Substantiated.

Deficiency issued on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.