complaint·March 25, 2025

There was no indication that the medications R1 is taking can produce false positives for cocaine and PCP. However, the hospital medical records showed that R1 was tested positive for felony drugs. The administrator and Staff were interviewed regarding this allegation. Per the administrator, no felony drugs were given to the resident. Staff interviewed denied giving R1 any illegal drugs and did not notice any signs of drug use. R1 did not behave differently prior to being hospitalized. The med techs stated they only administer medications that are prescribed by the physician, and they are careful in distributing the medications. LPA interviewed R1 who did not remember how resident fell but stated there was no usual item given by staff or visitors. Although R1 tested positive for cocaine and PCP, there is no evidence that the facility staff gave the drugs. Therefore, the allegation is unsubstantiated. Allegation - Resident sustained an unexplained head injury. LPA interviewed the administrator, Staff, and Residents on this allegation. The facility submitted an incident report to Licensing regarding Resident #1's fall in January. Resident #1 (R1) had a fall on 1/17/25 at approximately 2 a.m. and sustained a head injury. Per the administrator, R1 resided in the assisted living side at the time of the fall. Staff indicated R1 does not like to ask for assistance and would go to the restroom on own. For this reason, staff would ensure that the assistive devices are moved closer to the resident, and nothing is obstructing the walkway. Staff interviewed stated they check on R1 at least every 2 hours and remind resident to press the pendant if assistance is needed. R1’s son was aware of the resident's falls and was in communication with the administrator to move R1 to the memory care unit prior to the last fall. LPA interviewed 8 residents during today’s visit. All the residents stated staff check on them and will assist if needed. Although the resident sustained a head injury, there is no sufficient evidence to show that there is a lack of care/supervision. Therefore, the allegation is unsubstantiated. 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. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights was provided.