Complaint Investigation Report

One interviewed witness confirmed that the text message sent to facility staff on August 15, 2025 at 7:16pm indicated that medication count was accurate. Based on the review of C1's MAR for the month of August 2025, C1 was prescribed two medications, Depakote and Risperidone. There were a total of 8 days in August 2025 C1 did not receive their medication(s) evidenced by some days were either left blank or marked with a (-) which signifies "not given" per the administrator. LPA verified via the back of the MAR, progress notes, and/or the Social/Leisure/Recreation Log that C1 had home visits on seven out of the eight days and the medications were not administered at the facility but administered at home. C1 received both medications in the morning and afternoon as prescribed on August 8th. However, there were no documentation as to why medications were not given at bedtime on August 8th. One staff interviewed indicated that C1 went to program on Friday, August 8th and would get picked up by their family for a home visit over the weekend. Document shows that C1 had a home visit continuing on Sat, August 9th and Sunday, August 10th. Documents also prove that there were another week, C1 would have a home visit starting Friday and throughout the weekend.

Therefore, based on interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility mismanaged client's medication is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report including the LIC811 were provided at the end of the visit.