Complaint Investigation Report

The investigation revealed the following : Allegation #1- Staff are not providing residents with medication management.

The details of the complaint alleged that the facility has a centralized location to give residents their medication but if a resident forgets or oversleeps, then a dosage is missed. On 10/1/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R7) regarding the allegation. 4 of 4 staff denied the allegation that Staff are not providing residents with medication management. All staff (S1-S4) stated that the facility has a centralized location to give residents their medication, which is on the third floor in the medication room. They stated that those who are not able to come to the medication room to get their medication, it is taken to them by the medication technician, so it is not missed. They state further that they utilize Medication Administration Records (MAR) to chart medications given to residents and any missed or refused doses are written in the MAR and reported to their primary physician and family.

The department interviewed residents (R1-R7) about the allegation and 7 of 7 residents that were interviewed stated that they have not missed any medications due to the location in which they receive their medication. Additionally, they stated their medication has not been mismanaged by the staff.

The department reviewed a random sample of Medication Administration Records (Dated: 8/1/2025-9/30/2025) and did not observe any irregularities or deficiencies in the medication management of the residents’ records.

Based on observation, interviews, and records reviewed, there is insufficient evidence to support the allegation that Staff are not providing residents with medication management. 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 .

Allegation #2- Staff are not abiding by the terms and conditions of Admission Agreement.

The details of the complaint alleged that the facility is not providing activities for the residents (such as trips to the beach) or providing the residents with cable in their room per their admission agreement. On 10/1/2025, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R7) regarding the allegation.