complaint·January 26, 2026

Regarding the allegation: Staff did not ensure residents records were properly managed. It is being alleged that Resident #1 (R1) received a bill for blood they had withdrawn at the above facility. During LPA's interview with R1, R1 confirmed that they did not have proof of a bill that they were being charged on behalf of a blood draw. LPA interviewed sixteen (16) other residents that confirmed they have had blood withdrawn at the facility but they have never received a bill. LPA interviewed five (5) staff, four (4) out of the five (5) staff did not know about how a resident gets billed, they only provide medication disbursement. One (1) staff out of the five (5) staff confirmed that residents only get blood withdrawn at the above facility if their insurance covers it. Furthermore, that same staff confirmed if a resident's insurance refused to pay the bill they would get an email saying the resident's insurance was not covering the bill. In addition, that staff also confirmed that R1 gets Medical and Medicare and should not be getting charged for anything. LPA obtained R1's Identification and Emergency Information and Admission Record that confirms R1 gets both Medical and Medicare. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrative Service Coordinator. Regarding the allegation: Staff does not ensure residents medications are properly managed. It is being alleged that Resident #1-(R1) received a new pain medication and it was not provided to them. LPA asked for R1's MAR-Medication Administration Record and it was determined by reviewing R1's MAR, that the pain medication was never noted in the facility's medication system and on the MAR. LPA received R1's pain medication prescription from R1's new Health Insurance and the doctor that prescribed it. R1's medication was prescribed on 01/09/26. LPA conducted a physical review of R1's medication and noticed that pain medication was in a bubble pack stored in R1's medication packet in the medical technician's cart and the following dates were missing 01/20/26-01/26/26. It is a morning medication but there was no notation that it was being provided to R1. LPA interviewed the medical technician that confirmed R1's pain medication was provided that morning (01/26/26) but they did not document it anywhere because the new pain medication was not on the MAR list. Although, LPA interviewed sixteen (16) residents that confirm they receive their medication, R1 continues to confirm that they are not receiving their pain medication. LPA interviewed five (5) staff that confirmed that R1 should have been receiving their pain medication but because there was no documentation of R1 receiving their pain medication they cannot determine if R1 ever received it. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Administrative Service Coordinator.