Complaint·November 29, 2021

Therefore, based on observations and interview, the allegation " Facility grounds is in disrepair" is SUBSTANTIATED. Regarding allegation " Staff is mishandling clients medication while in care": LPA Colvin interviewed Administrator Danny Barrett and reviewed physical medication bottles and records from past resident (R1). LPA Colvin observed that while the facility's records for R1's medication Carvedilol stated that the staff were to administer 6.25 mg tablets broken into halves twice daily, the bottle for R1's medication was labeled as being 3.125 mg tablets, which were to be taken twice daily. Therefore, if the staff were cutting the 3.125 mg tablets, as instructed on the facility's medication records, then R1 was only getting half the prescribed dose of medication. Therefore, based on record review, the allegation " Staff is mishandling clients medication while in care" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted with Administrator Danny Barrett, and a copy of this report, LIC9099D, and appeal rights was provided. Regarding the allegation " Staff is not properly maintaining the facility": This allegation was specifically in relation to the facility's kitchen stove, which LPA Colvin did not observe any concerns with during the investigation. LPA Colvin additionally interviewed Administrator Danny Barrett regarding if there had been any issues with the stove, and Danny reported to LPA Colvin that they had one which was not working, so the landlord replaced it with a new one. Administrator Danny was able to show LPA Colvin on his computer and email exchange between himself and the landlord of the property in February of 2020, wherein the landlord states that they will come take a look at the problem. No further evidence was provided to LPA Colvin regarding this allegation. Therefore, based on observations, interviews, and record review, the allegation " Staff is not properly maintaining the facility" is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided to Administrator Danny Barrett. Regarding allegation " Staff is denying CCL representatives from inspecting the facility": LPA Colvin toured the facility, specifically focusing on where medications were stored, as well as what was stored in the Administrative office in the backyard. This allegation was specific to medication being kept in a secondary location (file cabinet in office), which Licensing was not given access to. LPA Colvin was granted access by the Administrator to medication both in the main storage area for the medication in the kitchen, as well as to the cabinet in the office. LPA Colvin confirmed the presence of medication in the cabinet in the office, but LPA Colvin was granted access to both the office and the cabinet by Administrator Danny Barrett without any difficulty. Therefore, based on observations, the allegation " Staff is denying CCL representatives from inspecting the facility" is UNFOUNDED. We have found the complaint is unfounded, meaning that the allegations are false, could not have happened and are without a reasonable basis. LPA Colvin conducted an exit interview with Administrator Danny Barrett and a copy of this report was provided.