Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff did not dispense medications as prescribed.

It is alleged that staff at facility were not dispensing resident’s medications as prescribed and administered PRN to R1 without consulting with responsible party before or after administering the medication. LPA conducted medication review, a total of 5 resident medications were reviewed with no issues observed. LPA reviewed R1’s MAR (Medication Administration Record) and did not observe any issues notations of medication being administered outside of the doctors’ instructions. LPA interviewed 4 staff and each denied the allegation, interviews with S3-S5 revealed that the Medication System that is used is very precise and does not allow medications to administer a medication before the allowed time. Staff also stated that contacting responsible parties is not a requirement when administering PRN unless the resident is not responding well to the medication, in which they will call family/responsible party/doctor and meet with them to create a plan/medication routine that will work best for the resident. LPA interviewed 5 residents and each denied the allegation and stated they do not have issues with the medication and believe medication is being given to them as prescribed.

Allegation: Resident sustained unexplained injuries in care.

It is alleged that R1 had an unwitnessed fall, sustained injuries from the fall and could not provide reasons or details of what happened. LPA reviewed R1’s file and within the Charting Notes (observations) R1 experienced a fall on 1/27/25 where resident was observed on floor near bed at 9pm with redness on right hip area and no major injuries, it is noted that family were contacted about the fall. LPA interviewed 4 staff and each denied the allegation and stated that falls at the facility are always documented and reported to the resident’s family and doctor (hospice if needed). Staff stated that residents are monitored post fall at all times and if the resident is injured, hits their head or complains of pain they call 911 to have the resident accessed. LPA interviewed 5 residents, and each denied the allegation and stated they have not had any unexplained injuries at the facility.