complaint·March 21, 2026

W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age of the complaint but denies facility wouldn't administer non-prescribed medication. Facility staff confirm physician orders are followed. LPA did not observe an order for Vitamin B on the resident's medication orders. Regarding the allegation that facility failed to provide supervision to resident resulting in resident pulling catheter out, the investigation revealed the following: Responsible Party and W1 confirm resident had a sitter at the facility as well as staff checking in every 2 hours. Once it was observed that the resident had pulled out the catheter, medical attention was sought immediately. The resident did not return to the facility after being sent out on this occasion due to declining health. Two out of two staff confirm residents on care are checked every 2 hours. Regarding the allegation that facility failed to properly store resident's medication, the investigation revealed the following: W1 states medications are delivered to the medication room and not to a resident's room. W1 does not recall an incident where insulin was observed to be in the resident's room especially since the resident was on med management. Two out of two staff confirm medications are not delivered to resident rooms. Regarding the allegation that facility staff failed to report resident's true condition to responsible party, the investigation revealed the following: W1 confirms sending condolences to the resident's family being inadvertently informed that the resident had passed. The hospital had mistakenly notified about the passing of the resident as the resident had not passed. The family was understandably upset but the notification came from the hospital and not the facility. W1 stated following what had been told to the witness. Due to the age of the complaint, LPA is unable to review parts of the resident's electronic medical record and staff interviewed do not remember the resident. Based on interviews conducted, the allegations are found 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. An exit interview was conducted and a copy of this report was provided.