complaint·July 3, 2025

The investigation revealed the following: Regarding the allegation “Staff did not dispense medication to resident as prescribed.”, it is being alleged that residents’ medication has not been provided under Dr.’s orders. Record reviews have revealed the following: Medications ordered for R1, R11 and R12 match the medication administration records that have been completed by medication management staff, which also match the medications ordered by R1, R11 and R12’s physicians’. Interviews revealed the following: Seven (7) out of nine (9) residents (R2-R8) and all seven (7) staff (S1-S7) have disagreed the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff did not assist residents with care needs in a timely manner.”, it is being alleged that staff do not provide care, as needed, to residents in care. LPA’s observations revealed the following: On 05/28/25, during LPA’s interviews with staff four (S4), in the medication room, LPA observed an emergency call from a resident’s room. LPA then heard a two-way radio for staff to investigate the same resident. Approximately four-minutes and thirty-two seconds (4:32) later, the call light had been switched off and staff have confirmed to have provided service to the same concerned resident. Interviews revealed the following: Seven (7) out of nine (9) residents (R2-R8) and all seven (7) staff (S1-S7) have disagreed the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff interfered with resident’s visits.”, it is being alleged that staff required a resident’s visitor to leave the premises. LPA’s observations revealed the following: On 07/03/25 LPA observed a sign outside the facility, noted as follows: “Visiting hours: 08:00AM – 08:00PM. . Record reviews have revealed the following: R1’s admissions agreement (dated: 07/31/23) have noted, on page thirty-one (31) out of sixty-five (65), “Guest / Visitor Log Visits and Visting Hours. Visitors are welcome in the community. Visitor hours are 7AM to 9PM. We ask that visitors become familiar with the signing the Guest Log upon their arrival and with signing out upon leaving the community. This register helps ensure the safety of our residents and keeps management and staff aware of who is in the building in case of an emergency or natural disaster. Visitors must abide by the Community’s rules and be respectful of residents and staff. All children must be properly supervised at all times.” Report continues, see LIC9099-C. Interviews revealed the following: All nine (9) residents (R2-R10) and all seven (7) staff (S1-S7) have disagreed the allegation has taken place. Based on LPA’s observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff did not provide requested records to resident's representative in a timely manner.”, it is being alleged that staff have not provided copies of a resident’s record(s) to the responsible party(ies) of a resident. Record reviews have revealed the following: a resident’s General Durable Power of Attorney, listed under section 1.01, initial agent is listed as “Agent John Doe”; yet under section 1.02, listed as “If “John Doe” fails to serve, I appoint “Jane Doe” to serve as successor Agent.”. However under section 1.04 Prior of Joint Agent Unable to Act “A successor Agent or an Agent serving jointly with another Agent may establish that the acting Agent or joint Agent is no longer able to serve as Agent by signing an affidavit that states that the Agent is not available or is incapable of acting. The affidavit must be supported by a death certificate of the Agent, a certificate showing that a guardian or conservator has been appointed for the Agent, or a letter from the Agent stating his or her unwillingness to act or delegating his or her power to the successor Agent.” all of which has never been provided to the facility or to Community Care Licensing Division. Interviews revealed the following: All nine (9) residents (R2-R10) and all seven (7) staff (S1-S7) have disagreed the allegation has taken place. Based on LPA’s observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff four, Tamera Gant Health and Wellness Director (S4) and a copy of this report has been provided.