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32 | (Continue from LIC9099)
Based on record reviews and interviews conducted on June 29, 2026, the investigation determined that the allegation stemmed from a miscommunication regarding medication management. Records showed that Resident 1 (R1) was admitted to the facility on June 1, 2026, with a diagnosis of Alzheimer's disease and was experiencing difficulty adjusting to the new environment, including exhibiting altered behaviors.
Interviews with staff and an outside source revealed that the Administrator had repeatedly requested that R1's responsible party contact R1's physician to obtain an evaluation for possible medication to address R1's behavioral changes. The outside source confirmed that the concern involved repeated requests to obtain a medication order and clarified that they did not report that facility staff administered medication belonging to another resident. The investigation also determined there was a delay in obtaining an evaluation because R1's physician was unavailable.
A review of R1's medication administration records and interviews with relevant parties found no evidence that facility staff administered medication that was not prescribed to R1 or medication belonging to another resident.
Based on observations, interviews, and record reviews, there was insufficient evidence to corroborate the allegation. Although the alleged incident may have occurred, the investigation did not produce a preponderance of evidence to support that facility staff administered medication belonging to another resident. Therefore, the allegation is deemed unsubstantiated.
An exit interview was conducted with Caregiver Mary Ann Joven and via telephone Administrator, Cook. A copy of this report, the LIC 811 Confidential Names List, and the Licensee Rights (LIC 9058 03/22) were provided at the conclusion of the visit. |