Complaint·July 3, 2025

Regarding the Allegation : Staff are not disposing of medications. This complaint alleged that the facility staff did not dispose of resident medication. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not disposing of medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff did not safeguard resident’s medications. This complaint alleged that the facility staff did not safeguard resident’s medications. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff did not safeguard resident’s medications.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not administering medications to residents. This complaint alleged that the facility staff did not administer medication to residents. LPA Calderon toured the facility with S1. LPA Calderon walked into the medication room on the second floor and witnessed staff preparing medications to be given to residents in care. LPA Calderon noted that staff work with an electronic Medication Administration Record (MAR) for dispensing the residents’ medications. The medications were locked in drawers and moved to locked medication carts which are used to move the resident’s medication. LPA Calderon noted there is a disposable bin for expired medications. LPA Calderon was shown the cabinet that holds liquid medications such as eye drops which were stored and locked. Records review indicate the following: Reviewed the MAR for April, May and June 2025 for R1-R9. Medications given to residents with no errors. Reviewed Physician orders for R1-R9, noted staff ordered medications for resident in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not administering medications to residents.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not following residents care plans. This complaint alleged that the facility staff did not follow the residents’ care plan. Records review indicate the following: Reviewed service plan for R1-R9, staff following service plan. Reviewed Physician report for R1-R9, staff following physician report for residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not following residents care plans” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff left residents in a soiled diaper for a long period of time. This complaint alleged that the facility staff did not dispose of soiled diapers for a long period of time. Records review indicate the following: Service plan for R1-R2 indicates full assistance with all aspects of bathroom activities and hygiene. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff left residents in a soiled diaper for a long period of time.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not bathing residents in care. This complaint alleged that the facility staff did not bathe residents. Records review indicate the following: Reviewed Service plan for R1-R9, assistance needed for showering noted by staff. Shower and Toileting logs indicate that bathing, grooming and toileting are provided to R1-R2 multiple times per day or per week. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not bathing residents in care.” is found to be UNSUBSTANTIATED. Regarding the Allegation : Staff are not feeding residents in care. This complaint alleged that the facility staff did not feed bedbound residents. Records review indicate the following: Reviewed Weekly Menu for residents in care, noted wide range of options to eat for residents. Breakfast, lunch and dinner are served. There is 1 st seating and 2 nd seating starting at 7am to 9am, lunch from 11 am to 1pm and dinner from 4pm to 6pm. Alternative menu is offered. Standard admission agreement indicates page A3-A4, section E meals: We will serve 3 nutritionally balanced meals and snacks daily to residents. Tray Service, we will provide a tray service to your apartment during an illness at no extra charge. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are not feeding residents in care.” is found to be UNSUBSTANTIATED Regarding the Allegation : Staff are teasing residents in care. This complaint alleged that the facility staff did not treat residents with respect. Toured the facility and did not notice any negative interactions with residents in care. Interviews indicate the following: 8 out of 8 staff deny the allegation. 12 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “Staff are teasing residents in care.” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Suzette Johnson (S1).