Complaint Investigation Report

Investigation consisted of the following:

On 07/02/2025, interviews were conducted, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 2 (R2) to Resident 11 (R11) were interviewed]. Resident 1’s (R1) records were gathered which consisted of Medication Administration Record (MAR) from 03/2025 to 04/2025; Unusual Incident Report dated 05/16/2025; Progress Notes from 03/2025 to 04/2025; Admission Agreement dated 04/07/2025; Emergency Information dated 07/02/2025; Resident Assessment dated 02/25/2025; Preplacement Appraisal Information dated 02/28/2025; Appraisal/Needs & Services Plan dated 03/05/2025; Consent Forms dated 03/09/2025; Personal Rights dated 03/09/2025; and other pertinent information. Facility records were gathered which consisted of Resident Roster; Personnel Report dated 04/2025; Personnel Report dated 07/02/2025; LVN-Medication Technician Job Role Description; Time-Sheets from 04/05/2025 to 04/06/2025; Fall Risk Mitigation and Prevention Policy; Inservice Training from 03/05/2024 to 03/19/2025; Plan of Operation; and other pertinent information. On 8/14/2025, interviews were conducted, and records were reviewed. Interviews conducted consisted of 9 staff interviews [Staff 1 (S1) to Staff 9 (S9) were interviewed] and 2 witness interviews [Witness 1 (W1) to Witness 2 (W2) were interviewed].