Complaint·April 29, 2024

LPA toured the facility on 12/11/2023 and did not see any mattress pads on the floor in the residents’ room. LPA conducted interviews with staff and residents with an interpreter present that did not provide any corroborating evidence that support resident was left on the floor for an extended period of time with no explanation from staff. Therefore, based on interviews, record review, and observation, the allegation “Resident was left on the floor for an extended period of time” is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility staff are mismanaging resident's medication” LPA conducted record review of the Medication Administration Record (MAR) for three (3) residents and found no discrepancies with the MAR and mediation count. Record review of the MAR and LPA’s observation of the medication reveal staff were administrating resident’s medication per the physicians’ orders. Record review and interviews with staff and residents reveal medication was being managed by staff and the residents were receiving their prescribed medication daily. Therefore based on interviews, record review, and observation, the allegation “Facility staff are mismanaging resident's medication” is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was reviewed with and provided to Licensee Danny Barret. Regarding the allegation “Facility staff are restraining residents” it was alleged Resident One (R1) had been restrained on their bed with two pillows placed by R1’s side to prevent R1 from moving. Interviews with Administrator Barrett revealed the facility puts two pillows on R1’s right side to keep R1 from rolling out of bed onto the floor. Record review revealed R1 has a history of falls per R1’s physicians report. However, there was no written care plan from a medical professional in place for R1 to have postural supports. Therefore, based on interviews and record review the allegation facility staff are restraining residents has been deemed SUBSTANTIATED at this time. 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 and a copy of this report, 9099C, 9099D, LIC 811, and appeal rights were provided to Licensee Danny Barret.