complaint·June 17, 2025

Based on interviews and documents obtained, staff confirmed that hand-over-hand and live pouring the medications is the preferred process. Staff are also providing residents with a water cup and water dispenser while administering medications. During the visit on 04/18/2025 LPA observed med tech (S5) administer mediation to several residents using the live pour method. The facility also uses a 3 rd party business to discard expired and unusable medication. The facility provided a copy of their bill which included the charge for discarding medication on 11/07/2024 and 03/07/2025. Through interviews with staff, all confirmed that if the resident is on hospice, that agency will dispose of their medications. If the resident is not on hospice, they will need multiple eyewitnesses and to sign off on the disposal. Based on interviews and records reviewed there is insufficient evidence to prove that facility staff is not properly administering medication to residents as prescribed causing residents to go to the ER due to lack of care. Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED - a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Based on interviews and obtained documents, the previous administrator (S1) left abruptly just before 12/25/2024. During this time the facility facilitated a replacement administrator and begun the onboarding process. On their first day, the new administrator (S2) did not show up and the facility looked to hire an internal employee. The announcement for the new administrator (S3) was sent to residents and families and set for 02/27/2025. During this time, period the facility did have an active administrator (S4) with an approved Administrator Certificate. Records reviewed show the Administrator is at the facility an adequate number of hours. Additionally, the administrator stated that they devote additional hours to the facility to fulfill their responsibilities when the need for such additional hours is needed. This department has investigated the complaint alleging the administrator is not present at the facility to meet facility’s operational needs and found out that the allegation was UNFOUNDED. Based on records reviewed, the above allegations are found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.