Complaint·October 20, 2022

Allegation # 2: Facility does not provide a comfortable environment for resident. On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records, and conducted a physical plant inspection. Based on today’s observations, and information obtained from staff and residents, the facility is always comfortable for residents, and the temperature met Licensing regulations. Therefore, based on today’s observations, and physical plant inspection, the allegation is deemed UNSUBSTANTIATED. Allegation # 3: Staff member made an inappropriate comment to resident. On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records. Through information obtained, LPA determined that resident # 1 (R1) caused tension and conflict with staff and other residents while living at the facility. LPA reviewed numerous incident reports, pertaining to the behavior of R1. Residents and staff who were present when R1 was at the facility, are gone, so LPA was not able to obtain further information. Current staff and residents did not witness the alleged inappropriate comment. Therefore, based on interviews and documentation, LPA determined the allegation is UNSUBSTANTIATED at this time. Allegation # 4: Facility did not maintain a resident's medication list . On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records. LPA observed the facility maintained resident # 1 (R1's) medication list and reviewed documentation from R1’s primary physician regarding the medication that was to be discontinued. LPA also obtained the medication administration record (MAR) obtained by the facility for R1. LPA observed no discrepancies, therefore, based on record review, LPA determined the allegation is UNSUBSTANTIATED at this time. Allegation # 7: Resident is paying for services not received. On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records. Information obtained and from interviews conducted, staff documented numerous incidents regarding the behavior and issues with resident #1 (R1) while in the care at the facility. It was also reported to LPA that R1 did not pay for rent for (4) months. LPA reviewed all documentation, and determined that the facility provided all services that was written in the admission agreement. LPA also determined there is insufficient evidence to prove the allegation, therefore, based on documentation and interviews, the allegation is UNSUBSTANTIATED at this time. Exit interview and copies of report provided. Allegation # 5: Staff did not fill/reorder resident's medications for an extended period of time. On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records. It was revealed to LPA by Administrators, that resident # 1 (R1) would drive to doctor visits alone without staff. R1 would not report or provide documentation such as any new physician or medication orders. Administrators attempted on several occasions to obtain medical information for R1. Administrators were denied any access to records and was instructed to obtain documentation from R1. R1 refused, therefore staff were not aware of current medical information for R1. It was also reported, that when staff cleaned R1’s private room, they found new medication RX’s and physician notes. Therefore, LPA determined, that R1 intentionally withheld medical information from staff, and medication stored by the facility was administered according to physician's orders. LPA was not able to interview R1, due to R1 no longer residing at the facility. Based on documentation and interviews, LPA determined there is insufficient evidence to prove the allegation, and it’s deemed UNSUBSTANTIATED at this time. Allegation # 6: Staff did not give resident medications according to physicians' orders . On July 26, 2021, from 930am to 1230pm, LPA Wendell Smith conducted interviews and obtain facility and resident records. During today’s visit, from 1130am to 315pm, LPA Tuesday Cabiness conducted additional interviews, reviewed facility, and resident records. It was revealed to LPA by staff, that resident # 1 (R1) would drive to doctor visits alone without staff. R1 would not report or provide documentation such as physician or new medication orders. Administrators attempted on several occasions to obtain medical information for R1. Administrators were denied any access to records and was instructed to obtain documentation from R1. R1 refused, therefore staff were not aware of current medical information. It was also reported, that when staff cleaned R1’s private room, they found new medication RX’s and physician notes. Therefore, R1 intentionally withheld medical information. LPA was not able to interview R1, due to R1 no longer residing at the facility. Based on documentation and interviews, LPA determined there is insufficient evidence to prove the allegation, therefore the allegation is deemed UNSUBSTANTIATED at this time.