complaint·August 5, 2025

During today's visit, LPA obtained the following documents: Staff and Client roster. LPA interviewed Witness #2 (W2) over the phone. The investigation revealed the following: in regards to the allegation: “Facility staff did not assist resident with obtaining medical care.” It is alleged that R1 had an untreated foot infection and several medical complaints that were often ignored by staff. One (1) out of nine (9) residents interviewed corroborated with the allegation. Eight (8) out of seven (9) residents interviewed denied the allegation. The Administrator and five (5) out of five (5) staff, W1, and W2 interviewed all denied the allegation. Based on staff interview, the Resident Care Director stated that R1’s foot infection is currently being treated by a wound care nurse that visits R1 twice a week. Based on record review, the wound care progress notes confirms that the wound care nurse has visited twice a week in June 2025 and July 2025 to help treat R1’s foot. Based on the Administrator, the Resident Care Director, and the Witness #1 (W1’s) interviews, physician assistant continues to visit R1 twice a week to treat R1’s foot. Based on interview, W2 stated that the facility staff is appropriately assisting R1 in being provided medical care and also stated that there are no issues. R1 stated on waiting for an oxygen device that hasn’t been provided yet. The Administrator, Resident Care Director, and W2 stated that the oxygen concentrator has been addressed to R1’s home health care and primary care physician and currently in process of providing R1’s request of receiving the oxygen concentrator. There is not enough evidence to substantiate. Allegation: “Facility staff did not dispense medications as prescribed.” It is alleged that the facility staff often neglected R1 for pain medication because staff believes that R1 is seeking pain medication in an attempt to get high. LPA reviewed a random sample of medications of R1 and (5) residents and all medications are given as prescribed. LPA interviewed two (2) staff that help administer and they all denied the allegation. Staff indicated that some staff who assist med techs in passing medications have received medication training. Additionally, staff indicated that they have not received any report or complaint about not dispensing medications as prescribed. LPA interviewed nine (9) out of nine (9) residents that receive medication management care all claim to receive all medication as prescribed from the staff and have never been administered the wrong medications by any staff managers. LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record from May 2025, June 2025, and July 2025, all medications are given as prescribed. There is not enough evidence to substantiate. Allegations: “Facility staff did not provide meals to resident,” and “Facility staff did not provide drinking water to resident.” It is alleged that R1 is being neglected by not eating in days and staff refuse to give R1 water. The Administrator and five (5) out of five (5) staff denied the allegations stating that they provide meals and water in the dining hall or deliver the meals and water to the residents’ rooms. The administrator and three (3) out of five (5) staff interviewed stated that drinking water is available all day in the dining hall. Nine (9) out of nine (9) residents interviewed denied the allegation and stated that they are provided meals and drinking water from the facility and the staff have not refused to provide meals or water to them. One (1) out of nine (9) residents stated on buying food from outside of the facility since the resident is dissatisfied with the food being provided at the facility. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.