Complaint Investigation Report

On three separate occasions, R1 left the facility for a home visit. During the first home visit it was observed by the family member that the resident did not have their own medication box but was provided another resident’s. The family called the facility and it was confirmed by the house manager that the medication box was in fact for another resident. During the second visit, it was observed that two of the resident’s medication only had one dose of medication left and did not have the refills. The family contacted the facility to inform them that there was only one medication left and asked if there was another refill available. The house manager notified the family member that they forgot to provide the family with the refill and would come meet the family halfway to provide the medication. R1 went on a third home visit, and it was learned that when administering night medication, it was observed that an AM medication that was packaged separately was not provided. The family did have extra medication to ensure that the resident had their PM Medication as prescribed by the physician. The family contacted the facility where it was learned that staff informed the family that the facility did not have any more refills for that medication at the time. Furthermore, it was learned through interview that staff informed the family and the service coordinator that the reason that there was no medication given was due to not having refills available and was currently working with the family to obtain a renewal. R1’s Medication Administration Record and Medication were reviewed. Based on observation, it was found that the medication for Vyvanse was refilled on a later date from the visit.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An immediate civil penalty for $250 is being assessed for the violation of 80075(b). This facility was cited for this violation from a prior visit on 06/02/2023.

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the Facility Designated Administrator,Julian Hawes and staff member, Andrea Rush via email. An electronic email read receipt confirms receiving these documents.