complaint·December 5, 2024

The investigation revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that several medications have gone missing from R1’s prescribed medication supply at the facility. LPA reviewed 6 residents medications (including R1’s) and there were no missing medications nor any issues with medication observed. LPA interviewed 5 staff and 5 out of 5 staff denied the allegation. S2-S4 work with medications and stated that there hasn’t been a time where medication went missing for R1, however, R1 has mentioned their fear of medication running out or not being provided but there has not been a time where that happens. Staff further stated to accommodate R1 and their concerns they now administer medications individually and have R1 sign for anti-psychiatric medication since that is the medication they have been most concerned about. R1 confirmed that the medication was of concern for them, yet they have never missed a dose and medications now are being given individually with R1 signing for their anti-psychiatric medication. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated they have never had any medications gone missing and have no concerns when it comes to medication. Allegation: Staff did not provide adequate transportation services to resident in care. It is alleged that on Nov 24, 2024 at 9am the facility transportation vehicle left R1 behind, resulting in R1 nearly missing a doctors appointment and being late. LPA reviewed transportation log for week of November 25-29, 2024 (Nov 24 th was a Saturday, the transportation bus is not available weekends), and there was no log for R1 during that week. R1 confirmed that the date was for Nov 25 th , and although they were not able to utilize the transportation bus (because the schedule was full) they were accommodated with an alternate source of transportation (uber) and were able to make their appointment. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that the transportation bus is available to residents on Mon & Tues (sometimes Fridays, if needed) and if for whatever reason the bus is full or residents have appointments on a different day, residents are provided with alternate transportation services. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that the facility offers a transportation bus for them at least 2 days out of the week and they are also offered uber in the case that the bus is not available, each resident also denied being left behind without any transportation for appointments. (continued on LIC9099-C) Allegation: Staff did not prevent resident from harming another resident in care. It is alleged that R2 harmed another resident and staff did not prevent the altercation and that R2 and R3 have threatened R1. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. Staff stated although there have been altercations between residents in the past, staff do their best to intervene and redirect residents when there is a dispute, if needed residents are offered a relocation of room or new seating in dining. Staff further stated that there have never been altercations between R1 and R3, however, disagreements have happened between R1 and R2. Staff stated that both residents keep their distance from each other and are located on opposite sides of the facility to avoid crossing paths. Both R2 and R3 denied the above allegation and stated they have never threatened R1 and deny wanting to cause any harm to R1. During interview with R1, resident stated that they have never been threatened nor assaulted by R3 but feel that because R3 is friendly with R2 something may happen. R1 stated that they have had arguments with R2 in the past over previous issues but have never been physically harmed by R2. Staff are aware of the differences between R1 and R2 and they monitor both residents when they are in the same common areas to prevent any potential altercations. LPA interviewed 10 residents and 9 out of 10 residents denied the above allegation and stated that staff do their best to intervene when there are altercations between residents and separate residents when these situations arise. Based on statements and interviews conducted with Staff and Residents, review of transportation log and medication, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided to Lizbeth Acuna .