complaint·February 6, 2025

orders and resubmitted them to the pharmacy. The pharmacy did not receive the updated prescriptions until 06/25/2023, at which point the medication was processed, filled, and delivered to the facility. R1 started the new prescription on 06/25/2023. After reviewing R1’s hospital records, LPA determined that the facility contacted R1’s primary doctor as soon as they became aware that the medication had not been received. R1’s doctor’s office then contacted the pharmacy to verify the prescriptions, and the medication was delivered once the orders were clarified. Therefore, the facility administered the medication according to the doctor’s orders once it was received from the pharmacy. Based on the documentation reviewed, there is insufficient evidence to support the allegation. As a result, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged that staff did not ensure a resident was properly positioned in bed, resulting in a fall. To investigate the complaint, on 07/23/2023 , 12/03/2024 , and 02/06/2025 , at various times between 9:45 a.m. and 3:30 p.m ., (LPA) conducted interviews and reviewed relevant documents. According to the information obtained, Resident #1 (R1) experienced a change in condition, prompting the facility to enroll R1 in its fall management program. LPA received an incident report documenting that R1 had fallen but sustained no injuries. Although it was reported that R1 may have been improperly positioned in bed, there is no evidence to substantiate the allegation. Therefore, based on the information gathered through interviews and document reviews, the allegation is Unsubstantiated at this time. Allegation # 3: It was alleged staff do not ensure infection control policies are maintained. To investigate the complaint, on 07/23/2023, 12/03/2024, and today, 02/06/2025, from various timeframes, between 9:45 a.m . and 3:30 p.m . , (LPA) conducted interviews and reviewed documents relevant to the allegation. According to the information obtained, there have been no recent reported cases of residents contracting shingles or exposing others to the infection within the facility. However, it was revealed that Resident #2 (R2 ) had shingles over a year ago but was quarantined and remained in isolation in their room. Staff reported that meals and medication were provided to R2 in the room to prevent exposure to others. Neither staff nor residents interviewed by LPA reported any instance of a resident walking around the facility with a serious infection. Therefore, based on the interviews conducted, there is insufficient evidence to support the allegation. As a result, the allegation is Unsubstantiated at this time . Exit interview and copy of report provided.