Complaint Investigation Report

during the initial visit. Records included but were not limited to staff training information, residents’ medication administration records, activity calendar and inventory records of residents’ personal belongings. LPA interviewed eleven (11) additional residents including resident#1 (R1) via-phone. On 12/08/2025 LPA, Alvizar-Ettima interviewed Staff #1- #4 (S1- S4) via-phone and requested additional clarification to complete the investigation.

During this visit at 10:50a.m. LPA and ASC conducted a physical plan tour and delivered findings.

It was alleged that non kitchen workers yell at hungry residents to go away. During interview with resident #1 (R1) indicated that they have not seen staff yelling at residents. Interview with additional residents consistently stated staff are respectful and do not yell at residents. Resident #12 indicated that the services are excellent at this facility. Interviews with the Director of Culinary and ASC revealed no complaints of staff yelling at residents. Other staff reported that they are always present during meal service and have not observed staff telling at hungry residents to go away. LPA did not observe staff yelling during the visits.

Based on interviews, observations, and records review, there is insufficient evidence to prove or disprove the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED.

2.) Staff are mismanaging resident's medications

It was alleged that unlicensed staff distribute sleeping pills and other medication at dinner time. Interview with R1 revealed medications as prescribed are provided and had no idea of sleeping pills being distributed at dinner. Staff revealed that all Med-Tech’s are trained at administering medications at designated times. Interview with additional residents confirmed the same practice. Resident #2 (R2) indicated that they take sleeping pills and med-tech always gives them to R2 at bedtime in their room. ASC reported that all Med – Tech staff are trained and certified to administer medications. A review of facility training records verified staff competency requirements. Interviews with staff indicated that medication distribution occurs according to policy and Med-Tech staff distribute medications in the dining room only when appropriate. A review of R2’s medication records showed no discrepancies and confirmed the information that R2 provided. There were no prior complaints regarding medication errors.