complaint·July 17, 2023

The investigation revealed the following. Regarding Allegation(s): Facility staff are not providing residents with keys to lock their room door- It is alleged that facility staff are not providing residents with keys to lock their room door. Two (2) out of five (5) staff interviewed acknowledged that not all residents have keys to their rooms due to some locks on residents’ doors to be is disrepair or not the keys themselves are not working correctly. Seven (7) out of the seven (7) residents interviewed currently do not have keys to lock their room door. Interviews and record review revealed three (3) out of seven (7) residents have been at the facility under 60 days and never received a key to their room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided. Facility staff are not re-filling medications in a timely manner. It is alleged facility staff are not re-filling resident medications in a timely manner. Four (4) out of four (4) staff interviewed deny this allegation. LPA Ramirez reviewed three (3) resident MAR for the months May, June and partial of July 2023. LPA Ramirez could not locate and discrepancy to suggest facility did not attempt to refill prescriptions. LPA Ramirez did locate notes in R1 file that indicated facility staff made several attempts to contact physician for prescription refill however, the physician’s office was delaying response. 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 allegation is UNSUBSTANTIATED . Facility staff are not safeguarding residents’ personal belongings. It is alleged the facility staff are not safeguarding residents’ personal belongings. Four (4) out of four (4) staff interviewed deny this allegation. Four (4) out of the seven (7) residents interviewed revealed they had items missing from their room in the past however, they did not notify facility staff because some stuff was of nominal value. Residents interviewed could not recall if they misplaced some items of if they were stolen from their room. R2 stated a new cellphone was stolen from their room several weeks ago. R2 revealed they did not notify the facility when the alleged theft occurred. LPA Ramirez could not locate a cell phone listed in R2’s itemized inventory list. 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 allegation is UNSUBSTANTIATED . Exit interview was conducted. A copy of this report was provided.