Complaint·April 10, 2025

Investigation revealed the following: Regarding the allegation, "Staff did not ensure medication dispensed to resident was as prescribed". It has been alleged that a resident's medication has been changed without notifying the primary psychiatrist or the responsible parties of a resident. LPA conducted record reviews of the changes mentioned in a resident's medication (MED) list, as follows: LPA reviewed an unusual Incident / Injury Report (LIC624) (dated 03/20/25) noting a resident was observed by staff nine (S9) to have altered behavioral and mental status. On 03/27/25, the resident's primary psychiatrist, sent a new order to this facility. LPA reviewed the facilities' order request on 03/29/25, to the pharmacy. On 04/10/25, between 10:00AM and 1:00PM, LPA interviewed seven (7) staff (S1-S10). S2 and S9 were not present at the facility nor available for LPA's interview call. Between 2:00PM and 4:00PM, LPA interviewed four (4) residents (R2, R4-R6). R1 was not available for interview. R3 preferred not to be interviewed. All eight (8) staff interviewed (S1, S3-S8, S10) and four (4) out of four (4) residents interviewed (R2, R4-R6) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Regarding the allegation, " Staff did not meet resident's dietary needs". It has been alleged that a resident requires a special diet, as ordered from their physician, and that staff do not follow a residents' special diet. Furthermore, a resident, at times, does not receive a meal from the kitchen. Between 10:00AM - 10:30AM, LPA observed the "diet report" posted in the kitchen. LPA requested facilities' communications between staff and management regarding any changes involving residents and their food and observed those communications between February, 2025 (02/25) and April, 2025 (04/25) which noted six (6) new residents, including their diet plan, and one (1) request to hold nutrition (fasting) for a resident. LPA conducted record reviews of the facilities' diet report and observed 105 residents' dietary restrictions. On 04/10/25, between 10:00AM and 1:00PM, LPA interviewed eight (7) staff (S1, S3). S2 and S9 were not present at the facility nor available for LPA's interview call. Between 2:00PM and 4:00PM, LPA interviewed five (5) residents (R1-R5). R3 preferred not to be interviewed. Report continues, see LIC9099-C. All eight (8) staff interviewed (S1, S3-S8, S10) and four (4) out of four (4) residents interviewed (R2, R4-R6) have denied the allegation has taken place. have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Mendy Ginsburg (S1) and a copy of this report was provided.