Complaint·July 18, 2025

Page 2 - Continued This Department investigated the following allegations: Facility staff do not respond to residents call buttons in timely manner: Multiple residents were interviewed and report that the wait times after pushing the pendent button are too long. Residents also say that care staff enter the rooms, clear the pendent and leave again saying they will return soon. A report was obtained of R1's pendent report for 3/17/25. R1 pressed the pendent once at 6:03am and it was cleared within the hour. Facility staff are not dispensing medication as prescribed: A review was conducted of R1's medications as well as an audit of the facility documentation of the Medication Administration Record (MAR) of February 2025. Family takes R1 home for days at a time, when this happens medications are checked out from the facility, given at home and brought back after the visit. The facility MAR indicates when R1 is out of the facility. Additionally, interview reveals that the MAR does not record the actual time the Med Tech (MT) gives medications to R1, the system only records the time the records in the computer. Based on interviews and record reviews the above allegations are UNSUBSTANTIATED . Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided to AD.