Complaint Investigation Report

Staff are mismanaging resident's medication

Based on documents obtained and statements reviewed for September and October of 2025, the department determined that there was insufficient evidence that any medication errors have occurred. Documents obtained show that all current medications were administered and logged correctly for residents per their doctor’s orders. Eight staff interviews (8) indicated that staff were not aware of any medication errors. Four resident interviews (4) expressed no concerns with medication administration. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Staff did not respond to resident's calls for assistance

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Based on call logs and interviews, the typical response time for staff responding to a resident’s call alert ranges from 5–12 minutes. Residents interviewed stated they have not had issues with staff not responding to call buttons timely. Staff interviews indicated that staff usually respond to resident’s call buttons within 10-15 minutes. Staff did state that occasionally after assisting a resident, staff will forget to clear the call button request whereas documents may seem that residents are waiting for assistance longer. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Report left with facility.