Complaint Investigation Report

On 02/24/2026, LPA Marrufo interviewed staff S1, who stated that there were no issues with distributing M1 and M2 to R1 as prescribed. S1 stated there was a doctor’s order to increase R1’s dosage of M1 from a quarter tablet to a full tablet.

R1’s Admission Agreement indicates R1’s admission date is 02/25/2025.

R1’s Medication Administration Record (MAR) indicates R1 was prescribed a whole tablet of M1 from 02/25/2025 to 03/04/2025. R1’s MAR states R1 was assisted with the administration of a full tablet of M1 from 02/25/2025 to 03/04/2025.

R1’s MAR indicates R1 was prescribed a quarter tablet of M1 from 02/25/2025 to 03/07/2025. R1’s MAR indicates R1 was assisted with the administration of a quarter tablet of M1 from 03/04/2025 to 03/07/2025. The boxes for 03/01/2025 to the morning of 03/04/2025 have an “x” in them, meaning the resident was not present at the facility when the medication was prescribed to be given.

On 03/25/2026, LPA Marrufo received a copy of a prescription order for R1. The prescription order called for a quarter tablet of M1. The prescription order did not have a date on it.

Allegation: Staff did not ensure that resident was provided a signal system specific to living unit

During visit on 08/12/2025, LPA Marrufo toured the bedroom that R1 lived in when R1 lived at the facility. LPA Marrufo pushed the Emergency Call Button which was installed on the bedroom wall near the bed. Within 3 minutes, a staff member came to the bedroom to check on the emergency call.

LPA Marrufo then went into the kitchen area where there was a panel that showed the emergency call came from R1’s former bedroom.

LPA took photographs of the Emergency Call Button in the bedroom and the panel in the kitchen area.