Complaint Investigation Report

pass. S8 indicated that the facility nurse instructed that the medications could be readministered to R1 without incident as they were provided to R1 within the window of time the medication can be administered. S9 indicated that, on one occasion (date unknown), they have witnessed R1 spit their medication back into the cup and then took it immediately after. S2, S6, S7, and S8 indicated that there are typically two staff members that pass medications together for verification purposes. The Medication/Treatment Administration Record for R1, dated January 2025, indicated that R1 received all of their medications. On April 22, 2025, LPA observed R1's bed and did not observe any medications in the bed.

Allegation: Staff are not reporting incidents

Interview with S2 indicated that everyone is a mandated reporter and required to report any incidents involving the residents. S2, S4, S6, S7, and S8 indicated that they report all incidents involving the residents. S5 and S9 indicated that they haven't had any incidents involving the residents to report. S4, S5, S6, S7, S8, and S9 indicated that they have never heard of a staff member not reporting incidents involving residents in care. LPA consistently receives incident reports from the facility.

Based on medication count, observation, documentation obtained, and interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.