complaint·October 23, 2025

3 out of 3 Med-techs interviewed reported R1 receives all their medication as prescribed. Witness 1 (W1) reported that R1 received more than the prescribed amount of melatonin, no dates or times were provided. W1 would not answer how they knew R1 received the wrong amount melatonin. There is no evidence to support the allegation, therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not ensure that resident ingested medications, revealed the following. It was reported that med-techs would give R1 their medication in a paper cup and then walk away and did not ensure R1 actually took the medication. 3 out of 3 med-techs interviewed denied the allegation. R1 did not respond to LPA’s questions. W1 reported that they never witnessed a med-tech walk away from R1 before they took the medication. 3 out of 3 caregivers interviewed reported they had never witnessed a med-tech give a resident medication and walk away before the resident took the medication. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident's records are not accurate, revealed the following. It was reported that R1’s resident information sheet (face sheet) had inaccurate information on it. No details were provided. LPA reviewed the information and verified the resident information, and the responsible party information was correct along with physician information. The Executive Director reported the information is correct to the best of their knowledge. R1’s responsible party would not verify any medical information. It is unclear what information was not accurate. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff is not communicating with resident's representatives in a timely manner, revealed the following. It was reported that the facility staff would not communicate with R1’s family regarding the status and condition of R1 or to provide requested documents like observation notes for R1. A review of incident reports for the facility for September and October 2021 shows only 2 incident reports submitted to the Agency and neither incident involved R1. There is no regulation regarding communicating with a responsible party unless it involves an incident that threatens the health, safety and welfare of a resident. The Executive Director stated that the Responsible Party/Power of Attorney for R1 has not requested any documents so none have been provided, and any other requests would be denied without the Power of Attorney’s permission. R1’s Power of Attorney reported that they have not requested any records for R1 and have no issues with communication with the facility. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not respond to the front door exit alarm in a timely manner, revealed the following. It was reported that Witness 2 (W2) exited the front door of the facility and the door alarm sounded and no staff responded to the door alarm. W1 reported that no one came to check the door. No date or time was provided for this incident. 1 out of 3 caregivers interviewed reported that they remember the incident. Staff 6 (S6) reported that they remember one afternoon (doesn’t remember the date) they saw R1’s family leaving the interior of the facility and exiting into the main lobby which has the front door to enter and exit the facility. S6 reported that the front door to the facility is not alarmed and does not make a sound when people open it. S6 reported that R1’s family pushed on the door leading to the lobby (which is delayed egress) and it opened, and the alarm went off and they left. S6 reported they were down the hall and saw that no residents were exiting and saw the door close and they walked up to the door and made sure it was secured. S6 stated that by the time they got to the door R1’s family had left. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff are serving food that does not meet individual needs, revealed the following. It was reported that the facility served R1 food that was unhealthy, high in salt and sugar and did not meet the needs of R1. A review of R1’s records show R1 was not prescribed a special diet. A review of the facility menu shows the facility is following Title 22 guidelines and the admission agreement which states that 3 nutritionally balanced meals along with snacks will be provided. LPA toured the kitchen and observed a two day supply of perishable food and a seven day supply of non-perishable food and observed all 4 food groups and observed fresh produce, dairy and proteins along with fresh bread and cereals. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.