Complaint Investigation Report

monitored. On 5/8/23, staff noted in R2's progress notes that at 11:48 R2 touched R3 in the lobby. Staff told R2 to stop and caregivers were notified. Then on 5/8/23, at 12:53, R2 then touched R4. On 5/15/23 and 6/1/23 progress notes similar unwanted touching of two other residents. R1's behavior was previously investigated and safety measures discussed with the Administrator to include measures to be in place for the safety of other residents.

Medications not refilled before supplies run out- LPA reviewed medication records for R5 and R6. Centrally Stored medication records, medication administration records and interviews found R5 and R6 had periods in May 2023 where medications were not administered with notations by staff of medication not available/ back ordered. Interviews found that the refill system lacked clarity of the process from refill request to tracking of refill delivery before R5 or R6 medication supply ran out. Staff were unable to provide records of physician contact or CCL reporting when R5 and R6 medications were not provided as prescribed.

Restricted health conditions not manage- LPA interviews of residents and staff found that staff, at times administered R7's insulin injections. Interviews found R7 is physically capable of administering their own inject. However, R7 would at times be resistant to administer their own injection so for expediency staff administer injections.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Admin . Copy of this report and appeal rights provided.