Complaint Investigation Report

***AMENDED COMPLAINT INVESTIGATION FINDINGS***

Per an interview conducted with DRP during that visit, a subsequent interview conducted on 02/12/2026, and an interview conducted with RP on 02/12/2026, LPA received consistent information from both parties that no privacy shield was put in place to ensure privacy for Resident 1 (R1) while having their briefs changed or receiving any sort of bedside care in their shared room. Facility has since purchased portable privacy screens and agrees to utilize them in shared rooms when providing any sort of care moving forward.

During the above mentioned interviews with DRP and RP, LPA received consistent information from both parties that that Staff 1 (S1) drew up R1's PRN narcotic and attempted to hand it to RP to administer to R1. Additionally, on 02/27/2026, LPA conducted a phone interview conducted with a representative from the third party Hospice agency which revealed that the narcotics prescribed for R1 were not delivered to the facility in pre-filled syringes for facility staff to assist R1 with administering the narcotic to themselves as required per regulation. Based on interviews conducted and records obtained, S1 should have contacted the Hospice agency nurse to come to the facility to assist R1 with drawing up and and administering their narcotics.

Based on observations made and interviews conducted, the allegations that s taff do not ensure residents are given privacy and unqualified staff attempted to administer morphine to a resident in care are SUBSTANTIATED . A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to DRP.