complaint·March 23, 2023

conflicted with the written physician's orders. Facility staff indicated that written physician's orders were required prior to changing the manner in which R1 could receive their medication and vitamin supplements. Throughout the investigation LPA Velazquez observed the common areas of the facility to be clean and well-maintained as were the resident rooms LPA observed. Four of six individuals interviewed felt safe and felt they were accorded a safe and secure environment while in care. Six of six individuals interviewed stated fluids are provided to residents throughout the day for their consumption. Four of four individuals interviewed stated that no resident has suffered dehydration while in care and further indicated all residents are provided with fluids throughout the day but that it was up to the resident to drink the fluids and stay hydrated. These four individuals stated all residents are encouraged to stay hydrated throughout the day when checking in the residents and they ensure fluids are readily available and easily accessible to residents. Four of four individuals stated R1's room was always clean and orderly. Based on the observations made by LPA Velazquez, interviews which were conducted and the records that were reviewed, 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 following allegations: Staff mismanaged resident's medication, Staff did not provide a safe environment for resident in care, Resident suffered from dehydration while in care, and Resident's room is unkempt are all deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington. A copy of the report was signed by ED Washington but due to technical difficulties LPA Velazquez was not able to print the report at the time of the visit. ED Washington agrees to receive the report via email along with the LIC 811.