complaint·October 22, 2025

conducted a record review of R1's medications and medication records. R1's medications are bubble pack. Review of R1's PRN Medication Log reveal that these medications were administered on 10/07/25 and 10/08/25 for agitation and yelling. Between 10:45am to 12:00pm, LPA interviewed four (4) of four residents. Interviews with these residents do not corroborate with the allegation. Moreover, during the ten day visit, LPA spoke with R1's family, who was at the facility at that time. R1's family raised no concerns regarding care and supervision, or of staff over medicating R1. Based on the information obtained, there wasn't enough evidence to prove that staff are over medicating R1. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not meeting resident's diaper needs: In regards to the allegation, it's being reported that on or around 10/06/25, R1 was observed to have dried gauze and stool on the buttock area. No witnesses were identified to corroborate this allegation. R1 is confirmed to be receiving hospice care by the reporting party. Between 8:45am and 9:45am, interviews with administrator and one (1) of one staff confirm that R1 is receiving hospice care, and as part of R1's hospice care plan, there is treatment for a Stage II Pressure Injury (PI) to R1's buttock. Administrator stated hospice nurse comes to check and treat R1's PI two to three times per week. Part of the treatment is to apply the gauze to R1's PI. Both administrator and staff deny ever leaving R1 with dried gauze or stool as they come into communication with hospice during the nurse's visits. Between 9:45am and 10:45am, LPA conducted a record review of R1's hospice care plan to confirm service. Between 10:45am to 12:00pm, LPA conducted interviews with four of four residents. These residents expressed no concerns regarding care and supervision and had no complaints of their needs not being met. Based on the information, there was insufficient evidence that staff are not meeting resident's diaper needs. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not ensure resident's medication was not accessible to other residents: In regards to the allegation, it's being reported that medications are not centrally stored and locked. According to the reporting party, a bottle of a prior resident's cream was left in R1's bathroom, accessible to the other residents in care. Between 8:45am to 9:45am, LPA interviewed administrator and one (1) of one staff who deny the allegation. Between 10:45am and 12:00pm, LPA conducted interviews with four (4) of four residents, who could not confirm the allegation. Between 12:00pm to 1:30pm, LPA conducted a physical plant inspection. Facility is a four (4) bedroom three (3) bathroom building. No medications were observed in any of these locations or any other common areas during the physical plant inspection. LPA checked the medication cabinet in the kitchen to be locked. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff no ensuring resident medications are not accessible to other residents. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are inappropriately limiting visitation time for resident: In regards to the allegation, it is being reported that visitation hours are only limited to thirty minutes per family visit. According to the reporting party, this is not enough time as they travel from a distance to come to this facility. Between 8:45am to 9:45am, LPA interviewed the administrator and one (1) of one staff. Both deny the allegation, stating family and friends can stay and visit for as long as the visiting hours permits. Visiting hours are between 9am to 6pm. Administrator stated, if a resident's family or friend needs additional time after visiting hours, she will accommodate, so long as the visiting time is reasonable and no overnight stay. Also visitors are asked to be mindful in keeping the peace with the other residents. Interviews with four (4) of four residents, between 10:45am to 12:00pm, do not corroborate with the allegation. No residents had any concerns that their friends and family visits have ever been limited to thirty minutes. During the ten day visit made by LPA Cava, R1's family was interviewed. According to R1's family, they've never been limited to thirty minute visitations. Based on the information received, there was insufficient evidence to prove that staff are limiting visitation time for the residents. Therefore, the allegation is deemed Unsubstantiated at this time.