complaint·May 29, 2025

every hour or every 30 minutes. Six (6) of six (6) staff interviewed revealed that they are checking on R1 at least every two (2) hours or more often if needed. All staff interviewed denied that R1 was neglected. Interview with Staff #1 (S1) indicated that R1 was sent out to the hospital in 09/12/2024 due to shortness of breath and mumbling words. Medical Records review revealed that the facility sent out R1 to the hospital after a staff observed R1 change of condition. Moreover, R1 was treated at the hospital for complaints and symptoms that are not keeping R1 with R1 overall wellness and condition. R1 was discharged to skilled nursing facility for continuation of care. In addition, records review revealed that on 06/23/24, R1 was diagnosed and being treated for a medical condition that can cause skin breakdown with possible bleeding in R1 lower extremity. It was noted that R1 has monthly follow-up appointments with R1 physician. The second allegation indicates staff is over medicating a resident. During the investigation, LPA Brown did not find any evidence to corroborate the allegation. LPA Brown was unable to interview R1 due to resident no longer living at the facility. Interview with seven (7) residents indicated that staffs are dispensing their medications as prescribed and there's no incident that staff over medicated a resident. Six (6) staff interviewed reported they have not witnessed or heard of an incident that a staff over medicating a resident. Two (2) Medication Technician (MedTech) staffs added that they are utilizing electronic Medication Administration Record (MAR) to ensure that they are giving the residents medications as prescribed. Both MedTechs denied over medicating R1. LPA Brown reviewed R1’s MAR and confirmed that staffs are dispensing R1's medications per R1’s physician orders and there was no evidence that staff overmedicated R1. Based on the evidence, the allegation that Staff neglect resulted in a resident to be hospitalized (Allegation #1), and Staff is over medicating a resident (Allegation #2) are 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 where this report, LIC9099, was discussed and provided to Assistant Administrator Mary Gonzalez.