Complaint Investigation Report

The investigation revealed the following:

Allegation: Unqualified staff are administering medications to residents

On 4/4/25, LPA Shirley reviewed, In-Service Staff Training completed on 11/23/24 and observed that S1 through S4 were trained for, Medication Administration. The topics included, Medications and Side effects, Prescriptions, Assisting with Medication Administration, and Documenting Medication Administration in the Medication Administration Record, (MAR).

LPA Shirley spoke with and interviewed staff 1 thru staff 4 (S1 thru S4). LPA asked if unqualified staff dispensed medications to clients. Of those interviewed, 4 out of 4 staff denied the allegation. LPA Shirley interviewed client 1 (C1). LPA asked, if he felt that staff are qualified to dispense medications to him. C1 stated yes, C2 was not available and C3 and C4 are nonverbal.

Regarding the allegation, “Unqualified staff are administering medication to residents,” the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Unqualified staff are providing care and supervision to residents.

On 3/31/25 LPA Shirley reviewed staff records and observed copies of DSP trainings for S1 through S4.