Complaint Investigation Report

On 7/13/22, LPA reviewed incident reports and complaints for January 2022 through July 2022. There were no injuries reported by the facility and no complaints regarding injuries to clients in care. On 7/13/22 and 8/24/23, LPA observed clients and did not find visible injuries. Based on the evidence obtained, the allegation, “Resident sustained injuries while in care,” is Unsubstantiated at this time.

On the allegation, “Staff are overmedicating resident,” the complainant was concerned that C1 was unresponsive to verbal communication and touch, and the concern was that it appeared C1 may be overmedicated. LPA interviewed the administrator and staff, made observations, and reviewed records.

On 7/13/22, the administrator and staff say C1 was not overmedicated and responds to their communication. Staff say they have not seen a change in condition and would report it to the administrator, if observed. LPA observed C1 and did not see any visible signs of unresponsiveness.

On 7/20/23, LPA reviewed C1’s Centrally Stored Medication Records (CSMR) and Medication Administration Records (MARS) for January 2021 – July 2022. Records indicate that C1 was being given the correctly prescribed medications and dosages during this period. There was no indication that C1 was being given any other medications nor being given dosages incorrectly. There were also no incident reports identifying medication errors for C1 during this time period. Based on evidence obtained, the allegation, “Staff are overmedicating resident,” is deemed Unsubstantiated at this time.

On the allegation, “Staff are not providing a comfortable environment for resident,” the complainant’s concern was that C1 was left alone in the living room with a client of the opposite sex and is concerned that something may happen. To investigate, LPA interviewed the administrator and staff and made observations.

On 7/13/22, the administrator states she has never witnessed client behaviors that could jeopardize the safety of other clients. She says there have been no incidents that would cause concern for clients to be temporarily alone with one another because staff are always with the clients. Administrator says the facility has working cameras in the common areas, if they had any concerns. Administrator says there is no verbal nor written agreement with any client’s authorized representative regarding clients not allowed to be alone with a client of the opposite sex in a common room. Staff interviewed say they have never seen any concerning behaviors among clients except for the clients occasionally trying to steal one another’s food. LPA observed cameras in the common areas: front entrance, living room, dining room, and kitchen.