complaint·August 19, 2025

The emergency binder contained all necessary and pertinent information for all 39 residents which included the face sheets, allergies, healthcare directives, emergency contacts, diagnoses, and etc. No concerns noted per review. Therefore, this agency has investigated the complaint and based on the records that were reviewed, the allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Roger Endert and Health and Wellness Director Lori Salas, and a copy of this report was provided at exit. Per review of R1's Order Summary Report for active orders, facility was administering five routine medications which did not include Trazadone as of February 27, 2025. LPA did not have sufficient corroborating evidence to conclude that facility was administering Trazadone between R1's start date of February 18, 2025 to March 5, 2025. In review of seven randomly selected residents' routine/PRN medications, two out of seven residents' medications were not given as prescribed: ten routine medications were not given for Resident #2 (R2) and four routine medications for Resident #3 (R3) for the month of February 2025. One out of six residents interviewed indicated that their PRN pain medication was not given as prescribed. One out of four staff confirmed that one resident's PRN pain medication was not given as it was unavailable. Regarding the allegation, Facility did not properly secure dangerous items, LPA along with Resident Care Coordinator Stephanie Najera observed and removed 31 prescription medications from R2's apartment on February 27, 2025. Per review of the Medication Self-Administration Safety Screening dated January 13, 2025, R2 was to begin on the medication management program on February 25, 2025. Facility did not ensure dangerous items which includes medications were removed from R2's room prior to being on the program. Regarding the allegation, Facility did not properly assess residents, it is alleged that the the Resident Care Coordinator was assessing residents in lieu of the Licensed Vocational Nurse. Staff #1 (S1) confirmed assessing three residents and indicated that it was the responsibility of a Licensed Vocational Nurse to perform this task which was corroborated per review of the job function description for the RCC and Health and Wellness Director. Therefore, it is determined that there were sufficient corroborating evidence to substantiate the above allegations. Deficiencies are being issued on the attached LIC9099Ds. An exit interview was conducted with Executive Director Roger Endert and Health and Wellness Director Lori Salas, and a copy of this report including the LIC9099-C, LIC9099Ds, LIC811s, and the appeal rights were provided at the end of the visit.