Complaint Investigation Report

Staff did not seek medical attention in a timely manner for a resident in care.

Interviews conducted with staff and resident R1 indicated that Resident R1 had an incident while on an outing with staff that required medical attention. R1 did not receive medical attention until the following day after the incident occurred. Records reviewed indicated that R1 did have a fracture to their foot which required a cast. Therefore, the allegation staff did not seek medical attention in a timely manner for a resident is care is substantiated.

Staff are not properly managing residents P&I money

Records review indicated that Resident R1 and R2’s P&I money was inaccurate to the ledger. It was written on the ledger that money had been used but the count of the money indicated that the money had not been removed or used. Therefore, the allegation staff are not properly managing resident’s P&I money is substantiated.

Staff did not keep facility free of bed bugs

Records reviewed indicated that Resident R1 had bed bugs in their mattress and room belongings in May 2025. Facility indicated that a pest control company came out to spray for bed bugs. Facility is now free of bed bugs and is continuing to have maintenance spraying done to prevent further incidents. Therefore, the allegation staff did not keep facility free of bed bugs is substantiated.

Staff did not administer medications as prescribed.

Records reviewed indicated that medication for Resident R1 was not administered as prescribed. Documented reviewed indicated that R1’s medication had one pill missing from the package but it was not documented on the Medication Administration Record (MAR) that is was given to R1. There were also medication bottle and packs that were not written on the Centrally Stored Medication Record (CSMR) to indicate that the medication was received and when the medication had been started. Therefore, the allegation staff did not administer medications as prescribed is substantiated.