complaint·March 27, 2025

Allegation: Regarding the allegation "Facility staff does not dispense residents’ medications as prescribed,” it is being alleged that staff are not regularly providing residents with their medications, and in some cases, they do not receive them at all. Resident #1 (R1) alleged medication #1 and medication #2 has not been given. R1 did not know the name of medication #2 but described why it is needed. Resident #2 (R2) alleged medication #3 is not given at nighttime. January and February 2025 Medication Administration Records’ revealed R1 received medication #1 as prescribed. On 03/20/25, LPA Cloyd observed medication #1 in stock. On 03/20/25, LPA Cloyd observed three medications that addresses the same condition as medication #2. These medications were dispensed as prescribed. R2’s January and February 2025 MAR revealed medication #3 was taken as prescribed. Six out of eight staff interviews indicated they have not received complaints regarding medication errors. Five out of six resident interviews indicated medication is being dispensed as prescribed. Three out of three residents interviews indicated that they manage their own medication. Regarding the allegation “Facility staff does not dispense residents’ medications as prescribed," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Facility staff does not provide comfortable accommodations to residents in care,” it is being alleged that Resident #1 and Resident #2’s room is extremely cold and heater and blankets are not provided. Five out of eight staff interviews indicated residents have complained about the room temperatures being too cold. Eight out of nine resident interviews indicated that it does get too hot and too cold. Six out seven residents indicated that staff respond with blankets or open their doors. Interview with the Maintenance Director indicated that the thermostat controls 10-15 rooms at once and different residents want different temperatures. We’ll leave it at 75 degrees cool so that it won't be too cold or too hot. If the weather is cooler then the heater is set at 75. LPA Anguiano observed the thermostat set at 72 degrees (first floor) and 73 degrees (second floor). Regarding the allegation “Facility staff does not provide comfortable accommodations to residents in care," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Facility staff did not provide residents with medical attention in a timely manner,” it is being alleged that Resident #1 (R1) and Resident #2 (R2) have been ill and have not received medical attention. R2 indicated that the illness was not reported. Record review of Care Transfer Log revealed thirty-one residents, including R1, were sent out for medical attention in January 2025. Care Transfer Log revealed nineteen residents were sent out for medical attention in February 2025. Seven out of eight staff interviews (S1 – 6, 9, 10) indicated that they respond to residents with medical attention in a timely manner. Four out six of resident interviews indicated they receive medical attention in a timely manner. Two out of two residents indicated staff sometimes responds in a timely manner. Regarding the allegation “Facility staff did not provide residents with medical attention in a timely manner," based on record reviews and interviews the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Regarding the allegation "Staff did not treat residents with dignity and respect,” it is being alleged that staff laughed at Resident #1 (R1) when R1 requested for medical assistance. Record review revealed six out of ten staff completed "Knowing the Rights of Residents" training. Nine out of ten staff interviews (S1 – S10) indicated they respond to residents with medical concerns with dignity and respect. Eight out of nine resident interviews indicate staff respond to them with dignity and respect. Regarding the allegation “Staff did not treat residents with dignity and respect," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director Brooke Lamotte.