Complaint Investigation Report

LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) .

The investigation revealed the following:

Allegation: Facility staff mismanage residents’ medications.

It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete.

On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs assist with self-administered medications when LVNs are unavailable. A1 reported she was not aware of any missed doses or medication errors.

On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications.

On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed ten (10) residents regarding the allegation. One (1) out of ten (10) residents confirmed the allegation. One (1) out of ten (10) was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. Of the one (1) resident who confirmed the allegation, the resident reported missed doses. Of the one (1) resident who was unsure mentioned being not sure of their medication management.