Complaint·April 2, 2026

Medication Administration Record’s for Resident 1 (R1) for December 2021, January 2022, February 2022, April 2022 and December 2022. Record review for MAR February 2022 revealed the following with medications in question, inhalers Symbicort and Trelegy. LPA observed two separate MAR’s for February 2022, one MAR had a note stating R1’s Symbicort inhaler was discontinued on 2/26/2022. On same MAR, shows R1’s Trelegy inhaler started on 2/24/2022 with a written note stating “re-write 2/26/2022” with initials. Second MAR for R1 shows Trelegy starting on 2/26/2022 with initials dispensed medication. Investigation revealed staff initials are unclear as to who marked each MAR. Guardian Pharmacy Services Audit report states R1 medications were reviewed on 3/10/2022 stating minor instructions regarding R1’s Trelegy Inhaler to swish around with water and no other discrepancies were notated on report. Interviews conducted with staff revealed that Medication Technicians, Nurse and Caregivers who have medication training can dispense medication to residents. Staff interviews revealed that staff who dispense meds need to document on an Electronic MAR (E-MAR) and if E-MAR is down or unavailable, staff are to document on paper MAR. Staff interviews stated that staff have to sign off on MAR’s regardless if resident takes meds or refuses, there needs to be a signature & note if refused. Interviews with staff stated that in order for new medications to be dispensed, facility needs medication to be uploaded in E-MAR, doctors order, and physical medication needs to be on hand. Interview with witness states that R1 was delivered new inhaler medication on 2/24/2022 and wasn’t given until later to start. Witness interview stated that R1’s Symbicort medication was discontinued and was still present in R1’s room 4 days later. Witness 1 states they feel facility is altering R1’s MAR and certain staff aren’t qualified to give out meds. Regarding Allegation Facility increased resident's rent without proper notification Record review conducted and LPA observed a notification letter from General Manager stating that a rent increase of $4275.00 will go into effect January 1, 2023 to December 31, 2023. Letter mentions that rate increases generally occur on anniversary date into community. Interview with Staff 1 stated that Notification of increase was given facility wide to all residents a year in advance due to facility not having fee increases in a long period of time. S1 stated that R1 was given a recent resident level of care increase not rent. Interview with Witness 1 states that when R1 was given March 2022 Bill that a $1000 increase in change in level of care that responsible party was not notified. CONTINUED ON 9099C Regarding Allegation Staff did not assess resident for change in level of care . Record review was conducted and LPA observed R1’s Resident Service Agreement dated 12/17/2021 with signed signatures from facility, responsible party and resident agreeing that R1 agreed to living accommodations for a care level of 4. LPA observed a Change in services forms dated 1/27/22 and 2/6/22 indicated that R1 changed from a level 4 to level 5 showing a care level increase of $370. A Change in services form dated 3/8/22 shows that R1 went back to a level of 4 care and increase was refunded. R1 had another change in services form dated 6/1/22 changing from level 4 to level 3 with a care decrease of $380. Staff interviews stated that Facility Nurse is the one who assesses residents for changes in level of care. Staff interviews stated that if a change in services form is completed then an assessment was recently conducted for resident. Interview with Witness 1 stated that no assessment was done and that Administrator claimed they completed one on 3/8/22 but Witness stated that Administrator did not wish to show Witness 1. Based on the conflicting information gathered from investigation, the allegations Staff are mismanaging resident's medication, Staff are not properly documenting the MAR, Facility increased resident's rent without proper notification and Staff did not assess resident for change in level of care are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred as reported. An exit interview was conducted with Executive Director Nestor Mendez and copy of report was discussed and provided.