Complaint Investigation Report

information obtained, it could not be proven that staff did not dispense R1's medication as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff did not ensure resident files were maintained:

In regards to the allegation, it was reported that an incident report for an incident, that had occurred on or around 02/24/24, regarding R1's medication was misfiled. It should have been reported that, on or around 02/24/24, R1's Quetiapine was not administered as prescribed by their physician. In reviewing R1's MAR, R1 never missed taking this medication, which would have warrant the facility to submit one if R1 did. Interview with the administrator, confirmed R1 did not miss their medication on that date, and that R1 is usually compliant with taking their medication. R1 could not recall whether or not medications were taken or missed on or around 02/24/24. Based on the information obtained, there was insufficient evidence to prove staff not ensuring files are maintained. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff did not report incident involving resident as required:

In regards to the allegation, it was reported that the licensee failed to submit incident reports involving R1. The first incident that the facility failed to report was their missed medication, which occurred on or around 02/24/24. The second incident report that the licensee should have reported was a personal rights incident involving R1, that occurred sometime on or around January or February of 2024. Regarding the first incident, that was alleged to have occurred on or around 02/24/24, LPA conducted interviews and record review, and there was no evidence that R1 missed taking their medication on 02/24/24. In regards to the second incident, LPA conducted a file review of the facility files and incident reports, that is logged into the Regional Office (RO) server electronically. LPA observed that there was a Serious Incident Report (SIR), reported and reviewed on 01/18/24, pertaining to R1's personal rights, which satisfies the licensees responsibility of reporting requirements. Based on the information obtained, there was insufficient evidence to prove that staff did not report incident involving R1 as required. Therefore, the allegation is deemed Unsubstantiated at this time.