complaint·March 10, 2025

CONTINUED FROM FORM LIC9099-A During the present visit, LPA conducted additional staff and resident interviews and requested additional records. Regarding the allegation that Facility staff mismanaged resident's medication , the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was prescribed with a Lorazepam prescription, as needed up to twice a day, by R1's primary care physician. Doses administered were adequately reviewed by staff members and do not appear to evidence any discrepancies between the quantities prescribed and the doses delivered by facility staff. Medication Administration Records reviewed did not evidence any discrepancies either. Regarding the allegation that Facility staff did not allow visitors during visiting hours , the following has been concluded: Based on interviews as well as a review of the facility's visitor logs for the period of April to July 2024 along with October and November 2024, it was evidenced that all residents, including R1 were able to receive visitors on multiple occasions. Visiting hours, house rules and admission agreements provided confirmed the agreed upon visiting hours. Multiple visitors were additionally witnessed during both inspections. As a result of the investigation, both allegations are found to be Unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit. CONTINUED FROM LIC9099 During the present visit, LPA conducted additional staff and resident interviews and requested additional records. Regarding the allegation of Wrongful Eviction , the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was admitted at the facility from Park Regency skilled nursing on May 20, 2024. R1 had a primary diagnosis of a wrist fracture, with additional indications of major depressive disorder and bipolar disorder. Following a reported incident of aggressive behavior towards staff members occurring on June 29, 2024, facility staff called the paramedics and R1 was transferred to St. Jude Hospital and admitted for psychiatric evaluation before eventually being discharged back to a different board-and-care. During the hospitalization, it was stated that hospital staff reached out to facility staff who declined to readmit the resident based on safety concerns. R1's care coordinated agency and responsible party relocated the resident at this time as home care was not an option. R1's responsible party were informed of the safety concerns and licensing staff was stated to have been informed of the situation by the facility's administrator, however no formal 30-day notices or updated reappraisals were conducted by facility staff. As a result, the allegation is found to be Substantiated, meaning that the he Department obtained sufficient evidence to corroborate the allegation mentioned above. The preponderance of evidence standard has been met. An Advisory Note for Technical Violation is issued on an attached for LIC9102. An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit.