Complaint·April 1, 2026

LPA also observed that the facility did not provide R1 her prescribed Olopatadine solution medication on April 20, and April 21, 2025, due to the facility not having the medication on hand, despite R1 having active orders for the medication. LPA conducted an interview with R1. R1 corroborated the allegation and reported that her medications were not given to her as prescribed on multiple occasions. LPA conducted six staff interviews. Four out of the six staff interviewed denied the allegation. However, two out of the six staff interviewed corroborated the allegation and reported that there were previous medication errors with R1's medication. Regarding the allegation, staff did not respond to resident's call button in a timely manner, the following has been concluded: It was alleged that staff did not respond to R1's call button in a timely manner on November 2022 and on July 2023. The facility was unable to provide any call button records for R1 from November 2022 or July 2023 due to their system not storing records for more than thirty days. However, LPA was able to obtain email records between the Reporting Party (RP) and the former Health Services Director, Staff #7 (S7). On an email dated November 18, 2022, S7 admits to the RP that it took staff forty three minutes to respond to R1's call button request on November 16, 2022. On an email dated July 17, 2023, S7 admits to the RP that it took staff ninety minutes to respond to R1's call button request on July 16, 2023. On an email dated September 20, 2025, S7 admits to the RP that it took staff forty five minutes to respond to R1's call button request earlier that day. LPA conducted an interview with R1. R1 corroborated the allegation and reported that she has had to wait extended periods of times to be assisted by staff after she presses her call button. LPA conducted an six staff interviews. Two out of the six staff interviewed denied the allegation. However, four out of the six staff interviewed corroborated the allegation and acknowledged that there have been incidents in which residents have had to wait extended periods of times to be assisted after pressing their call buttons. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff mismanaged resident's medications, and staff did not respond to resident's call button in a timely manner. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An exit interview was conducted with Health Services Director Angela Boyd. A copy of the report and Appeal Rights were provided.