Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation: Staff did not dispense medications to resident as prescribed .

It is alleged that the staff did not dispense and administer medications to resident# 1(R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. Four (4) medications were not transferred to the facilities’ pharmacy from R1’s previous pharmacy and therefore were not administered. Staff stated they communicated the medications and pharmacy issue to R1 and their POA’s. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list dated 4/01/25 listed fifteen (15) medications, four medications are shown as not administered. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly. The medical report dated 4/16/25, indicated R1’s attending physician suspected R1 did not receive medications at assisted living due to issues with the pharmacy. Staff dispensed all the prescribed medications transferred from R1’s previous pharmacy and awaiting approval from R1’s insurance to approval of the remaining. Medications log indicates all medications were prescribed were dispensed and administered to R1. Based on LPAs records reviewed and interviews which were conducted. 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.

Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner . It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. 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.