Complaint Investigation Report

It was also reported that medications were placed in a closed screw-top container, along with a closed bottle of water, and left for R1 to take unaided. On 7/26/2024, interviews conducted with Administrator. Administrator stated that the staff are to provide the medications to residents without the top on the container. Administrator and LPA observed the medications in the cabinet with the screw top containers. Administrator stated that the staff are to unscrew the container and provide the medication to the residents and make sure that they take the medication and not walk away. Administrator stated to LPA that she is not certain if the staff were providing the residents medication in this manner or not. Interview conducted with potential witnesses confirmed that staff #1 provided R1 with medications in a container with the top screwed on and walked away. Witness reported that medications were found on the floor and it was brought to the attention of staff. LPA made several attempts (08/9/24 at 6pm; 08/10/24 at 10am and on 08/11/24 at 2pm) to interview former staff (#1 and #2) however no return call was received. New staff hired was interviewed during the initial visit and they reported that they don’t handle the medications at this time. Administrator confirmed that she had multiple complaints regarding staff #1 and staff #2 therefore she terminated them.

Based on the above information gathered, there is sufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not properly administer a resident's medications” and “Staff mishandled a resident's medications” are deemed Substantiated this time.

Regarding Allegation “ Staff did not properly report an incident involving a resident ”: It was reported that R1 sustained a fall on 06/29/2024 which resulted in injuries and staff did not report the incident to the responsible person. Administrator reported that she was not aware that staff did not report the fall incident to R1’s responsible person on 06/29/2024. Interviews confirmed that R1’s fall was not reported to the responsible person.

Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Staff did not properly report an incident involving a resident” is deemed Substantiated at this time.

Regarding Allegation “Resident was charged excessive fees”: It was reported that R1 moved out of the facility on 07/06/2024. Interviews conducted with reporting party, Licensee/Administrator and resident records reviewed (Admission Agreement) revealed Licensee/Administrator did not issue appropriate refund to R1. (Continue to LIC9099c).