Complaint Investigation Report

Staff did not administer resident's medications as prescribed.

It was reported that on 12/02/2025 , facility staff did not provide medication to Client #1 (C1) . To investigate this allegation, LPA conducted interviews with the facility Designee and Staff #1 (S1) , interviewed clients, and reviewed C1’s medication records. The Designee stated they were not aware of any incidents related to the allegation. During the interview, S1 reported that C1 has two (2) prescribed medications :

Vitamin D3, 50 mcg , to be taken once daily with food , and

Loperamide 2 mg , to be taken as needed (PRN) .

S1 further stated that on 12/02/2025 , they attempted twice to administer C1’s Vitamin D3 by knocking on C1’s bedroom door , but C1 did not open the door or respond to either attempt. S1 also reported that C1 had been refusing to take Vitamin D3 from 11/29/2025 through 12/07/2025 . LPA reviewed C1’s Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) . Record review confirmed that C1 is prescribed two medications and showed missing doses of Vitamin D3 from 11/29/2025 through 12/07/2025 .

LPA also interviewed three (3) out of four (4) clients who were able to communicate. Two (2) of the three (3) clients stated they never missed their prescribed medications. One (1) client stated they did miss their prescribed medication and reported they were never offered medication by knocking on their door . This client also reported that they frequently remind staff about their medication and never refused to take their prescribed medication. Based on staff interviews, client interviews, and record review , there is sufficient evidence to support that staff did not administer medications as prescribed for C1. Therefore, the allegation is determined to be Substantiated.