Complaint·January 23, 2025

Regarding Allegation #1: Staff mishandled a resident’s medication. It is being alleged that staff mishandled 1 out of 6 resident medications. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. CCLD staff reviewed physician report (date 12/13/2024), needs and service plan (date 12/23/2024), admission agreement (date 01/09/2025), incident reports (date 12/21/2024 to 1/8/2025), MAR (date 1/2025) for 1 out of 6 residents. CCLD staff reviewed resident MAR and could not find any medication errors. 3 out of 3 staff denied the allegation and staff indicate that staff has never had any issues with any resident medications. 3 out of 6 residents indicate no issues regarding medications. 3 out of 6 residents could not be interviewed due to cognitive issues. Regarding allegation #2: Staff unlawfully evicted a resident. It is being alleged that a staff unlawfully evicted 1 out of 6 residents. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. CCLD staff reviewed physician report (date 12/13/2024), needs and service plan (date 12/23/2024), admission agreement (date 01/09/2025) for 1 out of 6 residents. CCLD staff could not locate any eviction notice given to resident. 3 out of 3 staff denied the allegation and staff indicate that staff never evicted any resident. 3 out of 6 residents indicate that staff has never evicted them for cause. 3 out of 6 residents could not be interviewed due to cognitive issues. Regarding Allegation #3: Staff is not meeting a residents continence need. It is being alleged that staff is not meeting 1 out of 6 residents continence needs. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. CCLD staff reviewed physician report (date 12/13/2024), needs and service plan (date 12/23/2024), admission agreement (date 01/09/2025) for 1 out of 6 residents. CCLD staff reviewed admission agreement for resident, facility states that incontinence supplies are not supplied by facility. Reviewed email between facility and resident conservator date 1/10/2025, email suggest that the facility will order supplies with insurance and resident family will need to pay for supplies not covered by insurance. 3 out of 3 staff denied the allegation and staff indicate that staff never had any issues with resident incontinence needs. 3 out of 6 residents indicate that they do not need incontinence supplies. 3 out of 6 residents could not be interviewed due to cognitive issues. Regarding Allegation #4: Staff are not providing adequate transportation to medical appointments. It is being alleged that staff are not providing 1 out of 6 residents transportation to medical appointments. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. CCLD staff reviewed physician report (date 12/13/2024), needs and service plan (date 12/23/2024), admission agreement (date 01/09/2025) for 1 out of 6 residents. CCLD staff reviewed admission agreement, page 1 section 2 “basic services”, indicates plan and arrange transportation to medical and dental appointments (paid by client), which was signed by resident conservator on 1/10/2025. 3 out of 3 staff denied the allegation and staff indicate that staff does not provide transportation for resident’s doctors’ appointments. 3 out of 6 residents indicate that staff does supply transportation for doctors’ appointments. 3 out of 6 residents could not be interviewed due to cognitive issues. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff mishandled a resident’s medication”, “staff unlawfully evicted a resident”, “staff is not meeting a residents continence need”, “staff are not providing adequate transportation to medical appointments” 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 Miriam Rudes S1.