Complaint·July 29, 2025

The investigation revealed the following: In regards to the allegation: “Staff did not ensure medications were dispensed and prescribed to resident in care.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, staff missed giving a resident their medication for a full day and failed to ensure that the resident received it. Interview with S1 revealed that medication for R1 was not administered as per the doctors’ orders because S1 failed to properly assess R1 prior to R1's transfer to the facility. Additionally, the paramedics who brought R1 into the facility did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. Due to this, S1 did not have a record of R1's current prescribed medications. S2 stated that she has not administered medications to any of the (3) current residents in the facility. Interview with R2 revealed that they do not take medications. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The la ck of documentation and interviews conducted corroborate this allegation. In regards to the allegation: “Staff did not inventory residents medications upon entry to the facility.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, the resident’s medication was left in the bag on the floor of the room and staff never checked the bag to check their medications. Interview with S1 revealed that the paramedics brought R1 to the facility on the evening of June 26, 2025. S1 stated that the paramedics did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. S1 indicated that R1 came in with bags of dirty clothes and inside the bag were R1's medications. However, S1 also stated that paramedics advised S1 to be cautious when handling R1 because of R1's medical condition that might be contagious while taking antibiotics. For this reason, S1 did not take an inventory of R1's belongings. Interview with R2 revealed that they could not recall whether their personal items were inventoried by the staff when they moved. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The lack of documentation and interviews conducted corroborate this allegation. Based on LPA’s interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Administrator, Kaylon Hallman along with the Appeals Rights.