complaint·August 27, 2025

On 8/27/2025 Licensed Program Analysts (LPAs),Edith Conchas and Renese Howell- Small conducted an unannounced visit to the facility to commence a complaint investigation. LPAs identified themselves and discussed the purpose of the visit with the Licensee Caroline Armstrong. During today's visit LPAs conducted observations, interviewed two staff, an agency caregiver and one (1) resident. LPA's also reviewed and obtained records. It is alleged that staff do not meet a resident's diabetic needs while in care. An interview with resident 1 (R1) revealed that R1 takes diabetis medication and gets their blood sugar checked in the morning by staff. An Interview with Staff 1 (S1) revealed that insulin was given this morning around 8:00 am. LP reviewed the records and audited medications of R1 which reveleald that several medications that were audited, were not listed on the Centrally Stored Medications list. S1 stated that R1 needs assistance with medication administration and S1 is the only staff that assists R1 with the insulin. Based upon record review, interview and observation, this alllegation is SUBSTANTIATED. It is alleged that staff mishandle the resident's medications. An interview with S1 and staff 2 (S2) confirmed that the hospice agency trained staff on general medications, not on diabetic medications and diet. S1 stated that some of R1's medication(s) have been disconitnued, however, LPA's did not observe any documentation to support this. S2 stated that the S1 places the residents' medication in small cups and designates when they are to be given. S2 does not document the date/time/dosage. LPA's did not observe any documentation that the medication(s) were administered nor any menu avaible for diabetes patients. LPAs observed a single loose pill in R1's basket of medications. Based upon record review, observations and interview, this allegation is SUBSTANTIATED.