complaint·April 30, 2025

LPA also interviewed staff and reviewed staffing schedules. Furthermore, during an annual inspection on 03/26/2025 randomly selected residents were interviewed regarding staffing and medication services. Regarding allegation “Facility staff mismanaged resident’s medication”: Interview with staff and records review revealed that Resident 1 (R1) lived at the facility until they passed away on 09/23/2024; R1 had a prescription for Morphine Sulfate 15mg and 20mg (tablets); records noted last fill date of morphine medication was on 09/21/2024 (20mg-tablets-as needed 3x a day). Medication Administration Records (MAR) indicated that on 09/21/2024, R1 received Morphine, which was prescribed by a physician solely for pain and comfort. Interviews with staff indicated that they did not have a problem filling R1’s medications on time. Staff denied the allegations. Records reviewed indicated morphine medication was provided according to physician and hospice instructions. Further interviews with the medication technicians and facility LVN confirmed that all controlled drugs are stored separately, recorded and inventoried at every shift. According to staff they never ran out of R1’s morphine. Interview with staff and records reviewed indicated that morphine was administered to R1 by a hospice and facility nurse following physician and hospice instructions. Controlled Substance Inventory form indicated facility had a supply of morphine for R1 until they passed on 09/23/2024. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, there is insufficient evidence to support the allegation. Therefore, the allegation “Facility staff mismanaged residents medication” is deemed unsubstantiated at this time. Regarding allegation “Licensee does not have enough staff to meet the needs of residents in care”: Interview with staff and facility records reviewed revealed facility staffing for the Assisted Living (AL) side with census of 35 residents, consist of three (3) caregivers; two (2) medtechs and Wellness nurse for both AM and PM shifts; NOC shift: one (1) caregiver and one (1) medtech; for the Memory Care unit with census of 15. Additionally, Five randomly selected residents of the assisted living side were interviewed and all five expressed no issues or concern with facility managing medications and care service. LPA attempted to interview residents in the memory care unit however residents were unable to comprehend questions asked due to lack of capacity. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Licensee does not have enough staff to meet the needs of residents in care” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.