Complaint Investigation Report

It is alleged staff gave R1 doses of medication without doctor’s consent. Interviews conducted with residents revealed 4 out of 7 residents stated their medication is provided as prescribed and 3 out of 7 residents were not able to provide information due to cognitive skills. Interviews with staff revealed medication technicians provide medication as prescribed by the physician. Documents review revealed, on 3/11/25 a medication clarification sheet was signed by nurse practitioner listing two orders of quetiapine, one for 25mg and another for 50mg. Medication administration record notes the same medications listed on medication clarification. Charting notes revealed, on 5/12/25 and 5/13/25 R1’s responsible party shared concerns about the medication dosage to medication technician. On 5/13/25 facility staff contacted nurse practitioner to address R1’s responsible party concerns. On 5/14/25 facility staff received new order of medication per R1’s responsible party request. Medication review did not reveal medication errors. Although the allegation may have happened the facility staff were providing medication as prescribed. Facility noted R1’s responsible party concern and address it with physician.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Facility staff handled residents in a rough manner and Facility staff yelled at resident. It is alleged staff aggressively sat a resident down and yelled at another resident. Interviews conducted with residents revealed 7 out of 7 residents stated that facility staff treat them well and respectfully. Interviews with staff revealed staff have not observed any other staff treat the residents in an aggressive manner or yelling at residents. Per administrator there have not been any incidents of staff treating residents disrespectfully report it. Training on Communication; Courtesy was provided to staff #2 on 4/22/25.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED .

Regarding allegation: Facility staff did not observe proper food service sanitation practices. It is alleged staff serve food with dirty hands and without gloves. Interviews with residents revealed 4 out of 7 residents stated staff take measurements to observe sanitation practices and 3 out of 7 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. (CONTINUED ON LIC 9099C)