complaint·January 30, 2026

The Physician’s Report dated June 15, 2023, states R1 was unable to administer own prescription medications but was able to self-administer PRN medications and safely store medications. The “Medication Release When Resident is Absent from the Residence” form indicates R1 and the daughter handled medications independently. The Personal Service Plan dated July 21, 2023, states R1 self-manages medications, including administering, ordering, coordinating, and storing medications safely. A witness reported concerns that the facility charged for medication management services while allegedly not providing adequate assistance and believed R1’s health decline was related to poor medication management. The witness also expressed concern that the facility delayed reassessing R1’s medication needs. However, the witness’s statements were not supported by facility records or corroborated by other interviews. LPA interviewed the facility’s Long-Term Care Ombudsman, who stated she regularly attends resident council meetings and has not received complaints or concerns regarding medication mismanagement. She indicated the most common concern is residents wanting medications administered exactly on time, noting the one-hour allowable window for medication administration. LPA interviewed eight residents. Most residents reported they manage their own medications. One resident reported medication management services were satisfactory initially but later experienced delays and forgetfulness. Two residents reported receiving medication management services and stated they had no issues. One resident receiving medication management services expressed a preference to self-manage medications due to cost; however, facility staff were following a nurse practitioner’s order requiring facility-managed medications. It was alleged that facility has not eradicated the cockroach problem. Upon investigation staff consistently reported the presence of cockroaches, sometimes referred to as water bugs, as a seasonal issue rather than an infestation. Staff stated the facility is located near a canal and that pests may enter through drainage systems. Staff reported the facility has taken proactive measures, including installing additional mesh barriers on drains to prevent pests from entering. Pest control records from Ecolab document monthly pest maintenance services, bait trap monitoring, and on-call services as needed. The Maintenance Director, Cristian Hernandez confirmed Ecolab services the (Complaint investigation continued on LIC9099C) facility monthly and that the facility maintains in-house pest control products for immediate response. He stated the facility avoids toxic chemicals due to concerns about water supply safety and emphasized ongoing pest management rather than complete eradication. LPA also spoke to the facility ombudsman stating there were no complaints or concerns related to cockroaches or pest infestations during resident council meetings. LPA interviewed eight residents, all of whom denied experiencing cockroach or pest issues and stated the facility responds appropriately to pest concerns. Therefore, based on record review and interviews, there is insufficient evidence to substantiate that R1 was not receiving medications in a timely manner due to facility noncompliance. Records consistently indicate R1 self-managed medications or shared responsibility with the daughter, and there is no documentation showing a failure by the facility to administer medications when responsible. Based on interviews and documentation reviewed, the facility has implemented ongoing and reasonable pest control measures and there is no evidence of an unresolved cockroach infestation. The facility demonstrated consistent pest management efforts and resident reports did not corroborate the allegation. The allegations mentioned above has been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director John Goodwin. A copy of the report and confidential names list were provided to the facility.