complaint·December 5, 2025

Allegation #1: Staff did not ensure that the resident's hospice care plan was followed . The complaint alleged that resident #1 (R1) was receiving hospice care and that the hospice agency provided the facility with a care plan for pain management. However, the facility reportedly refused to administer pain medication to R1. On December 4, 2025, LPA Richard interviewed Administrator #1 (A1), who denied the allegation, stating that the medication technician would follow the hospice and doctor's orders for all residents. A1 also mentioned that all staff members responsible for administering medications had received proper training. During the same period, LPA Richard interviewed five residents (R1-R5), all of whom denied the allegation. Additionally, LPA interviewed four staff members, #1-4 (S1-S4), who also denied the allegation. LPA Richard reviewed medication records and PRN medications on December 4, 2025, confirming that all residents received their medications without discrepancies. LPA also examined the facility's notes, which verified that no medication errors had occurred and that no medications were missing from any residents' medication records. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations occurred. Therefore, the allegation is unsubstantiated. Allegation #2: Staff did not ensure medication was dispensed as prescribed. The complaint alleged that the facility refused to provide R1 with pain medication. On December 4, 2025, LPA Richard interviewed Administrator #1 (A1), who denied the allegation. A1 stated that the medication technician would adhere to the hospice and doctor's orders for all residents. A1 also explained that staff would not administer any medications to residents without a doctor's orders. If the pharmacy fails to send the doctor's orders, the medication technician would call the pharmacy to request that they fax the orders to the facility. During the same timeframe, LPA Richard interviewed five residents (R1-R5), all of whom denied the allegations. Additionally, LPA Richard interviewed four staff members (S1-S4), all of whom also denied the allegations and affirmed that they followed the doctor's medication orders for all residents. On December 4, 2025, LPA Richard reviewed the medication records and PRN (as needed) medications, confirming that all residents received their medications without discrepancies. LPA Richard also examined the facility's notes and MARs, which confirmed that no medication errors had occurred and that no medications were missing from any residents' medication charts. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations occurred. Therefore, the allegation is unsubstantiated. Allegation #3: Staff does not ensure medical supplies are properly managed for residents in care. The complaint stated that the licensee fails to ensure that insulin medical supplies are reordered promptly. On December 4, 2025, LPA Richard interviewed the Administrator (A1) regarding the allegation. A1 denied it and explained that the facility does not administer insulin or order insulin supplies for any residents. LPA interviewed four staff members #1-4 (S1-S4), who denied the allegation. The facility does not use needles but provides a comfort kit for residents on hospice care. LPA inspected the facility's medications and supplies and found that it has sufficient medicines and supplies for all residents. LPA observed a first aid kit at the facility. On December 4, 2025, LPA interviewed residents #1-5 (R1-R5), who stated the staff takes good care of them. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations occurred. Therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Administrator, Venkata Sivaganesh Mullapudi.