Complaint·May 14, 2025

As part of the investigation, LPA interviewed staff #2 (S2) who was training S1 on the day of the incident and stated that S1 was in training, and both stayed to ensure that R1 took all the medications then they left the room. After the investigation, this allegation is unsubstantiated because there was no mistake made with R1’s medication administration. It was an accident that R1 almost dropped a pill while taking his/her pills but both staff members followed R1’s evaluation and plan and stayed with R1 to ensure R1 took all the medications before exiting the room as this was observed by the responsible party. Regarding to the allegation of staff did not ensure resident’s medications were refilled in a timely manner, the reporting party stated that on March 30, 2025, the responsible party received a call from the facility reporting that two of R1's medications were running low but the facility had enough to last for a few more days. On the next day (March 31, 2025), the responsible party received a from R1 at 7:01pm and stated that he/she did not take one of the medications that was running low. Subsequently, the responsible party called the facility and verified the medication ran out and delivered the medication that night. The responsible party also stated that the facility was supposed provide notification when R1’s medication has less than two weeks supply. According to the Memory Care Director, the facility has two types of medication refill systems for the residents. When the facility is managing the medications, the facility is responsible to ensure all the refills are done and when the resident or their responsible party is managing the medications, they will be the one to keep track of all the refills and the facility will make a courtesy call 2 weeks before the medications run out. The Memory Care Director stated that R1’s medication is managed by R1’s responsible party and S2 conducted the courtesy call 2 weeks prior to the medications were running low. LPA interviewed S2 who stated that he/she conducted a courtesy call 2 weeks in advance to the responsible party informing them that R1's medication was running low. Based on the documents provided by the facility, under Resident Evaluation, it indicated that R1 does not receive medication administration assistance from the facility instead, resident or family manages all aspects of the refills, including ordering and delivery of medications. Based on 24 hours shift report, it was documented by staff that on 3/30/2025, a courtesy call was made to R1’s family for the refills. After the investigation, this allegation is deemed to be unsubstantiated because R1’s family is managing R1’s medication and courtesy calls were made for the refills. Although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the memory care director. A copy is provided.