Complaint Investigation Report

Review of R1’s electronic progress notes also listed R1 to have a seafood/shellfish allergy. Based on record review, this allegation is Substantiated .

“Reporting Requirements” – Complaint alleged that R1’s responsible party was not notified of a fall or bruising found on R1 in September 2025. Per complaint, R1 had two falls in September 2025. R1’s primary contact was unavailable in September 2025 and the facility was to call the secondary contact listed for R1. Complaint also stated that R1’s secondary contact was informed of R1’s falls in September 2025 by voicemail.

Review of facility documents showed that on 09/18/2025, R1 was found on the floor by facility staff. Per document, R1 denied hitting their head and denied any complaints of pain. Facility staff notified R1’s responsible party and Primary Care Physician. Review of Physician Communication dated 09/18/2025 showed that facility informed R1’s Primary Care Physician of the fall.

Review of facility documents showed that on 09/25/2025, R1 was observed to have bruising on their back while having their clothes changed. Per document, R1 informed facility staff that they had fallen earlier in the day but did not report it to facility staff. Review of facility’s internal incident report and physician communication dated 09/25/2025 showed that R1’s responsible party and Primary Care Physician were notified. Interview conducted with R1’s secondary contact revealed that they received a voicemail regarding R1’s falls in September 2025. This interview further revealed that they were not informed of any bruise on R1 and that they did not receive a written report from the facility regarding R1’s falls.

During the course of the investigation, it was revealed that R1 was served a meal containing their food allergen in May 2025. Interview conducted with facility staff confirmed that the incident occurred. It was observed that an incident report was not submitted to Community Care Licensing as required for this incident. It was also observed during a medication audit that multiple errors occurred in the administration of medication for R1. These medication errors were also not reported to Community Care Licensing as required.

Based on record review, observations made, and interviews conducted, this allegation is Substantiated .

“Medication Mismanagement” – Complaint alleged that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required, did not have a urinary analysis test completed timely, and did not receive their PRN epinephrine pen after having an allergic reaction. Complaint also stated that R1 did not receive their levothyroxine medication correctly.

Complaint stated that R1 did not receive their “as needed” or PRN nystatin powder for groin rash as required. Review of R1’s facility documents stated that R1 is able to communicate their PRN or “as needed” needs and can inform facility staff when they need or want a medication. 5 of 6 staff interviews reported that R1 has the ability to communicate if they need or