Complaint·March 29, 2024

Continued.. Regarding the allegation Staff mismanaged the residents' records. Facility staff did not have required Centrally Stored Medication Log for Resident 4's medication being stored by the facility. Resident 6's medication being stored by the facility is not logged on the facilities Centrally Stored Medication Record. Based on LPA interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided. Continued.. Regarding the allegation Staff did not ensure that facility has hot water for the residents. LPA's interviewed five facility residents who all stated the facility has hot water. Resident 2 stated there was an incident during a weather related power outage where they did not have hot water for a few hours, but it was fixed before the day was over. Administrator stated recently during a weather related power outage there was a maintenance issue when the power was restored effecting the facility hot water. Administrator stated maintenance was notified, and the hot water was restored within the same day. LPA Hurt measured several facility resident room water temperatures to be within required 105 and 120 degrees. Based on interviews conducted, 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. Regarding the allegation Staff did not respond to the residents' pendants when asking for help. LPA's interviewed 5 facility residents who all stated despite having to wait longer at times on the weekends they are assisted timely when they push their pendant. Resident 3 stated when she pushes her pendant facility staff come fast to check to see if assistance is needed. LPA Hurt facility records titled "Device Activity Report" which documented wait times for assistance to be on average under 15 minutes. Based on interviews conducted, and records reviewed, 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 conducted with Administrator, Billy Mitchell, and a copy of this report, along with appeals rights provided.