Complaint Investigation Report

Interview with staff revealed that medication was issued to R1 when requested but the call button was not cleared by error. Medication administration records reviewed revealed that R1 was issued pain medication at 1:48pm and an anxiety medication at 2:59pm on the same date. According to pain medication prescription, medication can only be issued up to every two hours. Interview with an outside source did not confirm that R1’s call button was not answered in a timely manner.

It was also alleged that staff allow R2 to be left in urine-soaked clothing for an extended period. On February 18, 2025, LPA Strong interviewed R2 and found that R2 can change own clothing and can go to the bathroom independently. Interview with staff revealed that R2 does not like using incontinence pads and often does not use them. Interview former Director of Memory Care revealed that R2 must be convinced to receive incontinence assistance and their bedding is changed multiple times per day. Records revealed that R2 is incontinent of the bladder/bowel.

Based on multiple interviews and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Kimberly Garcia to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.