Complaint·October 25, 2024

Investigation Revealed the Following: Allegations: Staff did not accept resident back into care following hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed Luz Rose, Administrator who was asked if staff did not accept resident back into care following hospitalization, and the Administrator stated there were no concerns or issues. Per the Administrator, Luz Rose, they had a resident that required a higher level of care. On 02/22/2024 and 03/28/2024, the department interviewed staff 2-staff 8 (S2-S8) regarding the allegation staff did not accept resident back into care following hospitalization, of those interviewed S2-S8 stated there were no concerns about resident being let back into the facility after hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed witnesses #1 - witnesses #3 (W#1-#3). Of those interviewed W1-W3 stated there was an issue accepting resident back into facility after hospitalization. On 02/22/2024 and 03/28/2024, the department interviewed residents #1 - residents #8 (R#1-R#8). Of those interviewed 8 out of 8 stated they did know of anyone resident who has not been accepted back into the facility following hospitalization. The department attempted to interview R9, but they refused. On 02/22/2024, 03/28/2024 and 10/21/2024, the department conducted record reviews. Records show communication between facility, hospital, and a skilled nursing facility. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not accept resident back into care following hospitalization. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUE TO LIC9099C Allegation: Staff attempted to administer resident’s medication by force On 02/22/2024 and 03/28/2024, the department interviewed Luz Rose, Administrator who was asked if staff attempted to administer resident’s medication by force, and the Administrator stated there were no concerns or issues. Per Luz Rose staff does not administer resident’s medication by force. On 02/22/2024 and 03/28/2024, the department interviewed staff 2-staff 8 (S2-S8) about staff attempting to administer resident’s medication by force, of those interviewed S2-S8 stated the staff does not administer resident’s medication by force. On 02/22/2024 and 03/28/2024, the department interviewed residents #1 - residents #8 (R#1-R#8). The department attempted to interview R9, but they refused. Of those interviewed 8 out of 8 stated they did know of any resident that had been administered medication by force. Based on interviews and observations there is insufficient evidence to support the allegation: Staff attempted to administer resident’s medication by force. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview with Luz Rose Executive Director and a copy of this report and appeals rights provided.