complaint·April 23, 2025

The investigation revealed the following: Allegation: Staff did not dispense medications to resident as prescribed. On 4/23/25, LPA Shirley observed medication training certificates for all three staff. LPA observed the Medication Technician schedule and saw that there are 2 medication staff in the morning, 2 in the evening and 1 on the Nocturnal shift (NOC). The Wellness Director assist the team as needed. LPA Shirley monitored S5 dispense medications through the QuikMar system to five residents during lunch. S5 matched resident’s picture and name to resident, and dispensed medication according to time of day and dose prescribed by doctor. Once the medication was dispensed the picture turns grey to indicate that medication was administered. LPA Shirley confirmed that MAR matched physical medication. Per interview with Wellness director, there were there were an additional six Medication Technicians hired with a start day of May 1 st . LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff dispense medications to residents as prescribed. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-9 (R-1 thru R-9). LPA asked, does staff dispense your medications on time as prescribed. Of those interviewed, 6 out of 9 answered yes, 2 answered, no and 1 resident administered their own medications. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not assist resident with incontinence care needs in a timely manner. On 4/23/25, LPA Shirley Reviewed the incontinence schedule for 2 residents and observed that residents are being changed every 2 hours. Per interview with 5 staff members residents are changed every 2 hours or when called. Per interview with Wellness Director, the facility is short staffed and there were eight additional caregivers hired with an estimated start date of May 1 st . LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff assist residents with incontinence care needs in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-9 (R-1 thru R-9). LPA asked, does staff assist you with your incontinence needs in a timely manner. Of those interviewed, 5 out of 9 answered yes, and 4 stated that they were independent. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, 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 deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Wellness Director, Brooke LaMotte.