complaint·July 3, 2025

Continued from LIC9099 p.1) The prescription was administered at 8:00am and 8:00pm per the prescription order. LPA observed the medication packs in question, which contained R1's name and prescription. The tablets for the prescription were noted to be green in color. The investigation did not give evidence that a medication error occurred or that R1's seizure was related to medication. It was alleged that staff left Resident 1 (R1) in a soiled diaper for an extended period of time. Six (6) staff members were interviewed regarding the allegation. Staff members consistently informed that R1 was checked and assisted with incontinence care every 1-2 hours or more frequently due to R1's diet causing frequent bowel movements. Staff informed that R1's responsible party contacted the facility multiple times per day to make requests regarding R1's care, including for R1 to be changed. No staff had observed R1 not being changed timely or left in soiled briefs for an extended amount of time. An independent investigation was conducted by an outside source protective agency. The outside source informed that their investigation did not produce evidence that staff left R1 in a soiled brief for long periods of time. Review of facility records did not corroborate the allegation. R1's care schedule during the timeframe in question showed that R1 was checked for incontinence care in the morning, noon, evening, and night shift. Records also showed that the facility tracked the frequency and size of R1's bowel movements. A notice of care increase dated 08/27/2024 outlined the care tasks being provided to R1, which included incontinence care. R1's appraisals, Needs and Services Plan, and Physician's report all specified that R1 was incontinent and required assistance with toileting. Text messages between R1's responsible party and staff showed that staff were responsive to the responsible party's requests regarding R1's care. The information gathered evidenced that staff met and provided assistance with R1's incontinence care needs. No evidence was found that R1 was left in a soiled brief for an extended period of time. It was alleged that neglect/lack of supervision by staff resulted in sexual activity between Resident 1 (R1) and Resident 2 (R2). Interviews with staff who were present at the facility during the time of concern confirmed that R2, who had a baseline behavior of walking around the facility, did enter R1's room and lay on R1's bed. However, staff informed that R1 was not in the room during the time nor was R1 in their bed during this incident. (Continued on LIC9099 p. 3) (Continued from LIC9099 p.2) Staff informed that the person who made this claim manipulated the incident. Staff informed that R2 was known to walk the facility and sometimes lie in other residents' beds, but never when another resident was in the bed. Staff informed that R1 was in the living room when R2 was found in their bed, and no contact was made between the residents. An independent investigation was conducted by an outside source protective agency. The outside source (OS1) informed that their investigation did not produce evidence that any sexual activity occurred between R1 and R2. OS1 informed that a person known to R1 found R2 in R1's bed, but R1 was not in the bed. OS1 believed that the situation was manipulated for personal gain. No records were found to refute or confirm the allegation. During an unannounced facility visit LPA directly observed R2 walking around the facility. R2 could not be qualified as a valid historian due to impaired cognition. LPA did not observe R2 enter other resident rooms during the visit or have any altercations with another resident. It was alleged that Licensee did not answer communications from resident's representative promptly. Five (5) staff were interviewed regarding the allegation. Staff members unanimously informed that R1's representative called the facility numerous times per day, texted them on their personal phones, visited the facility, and made frequent requests and demands regarding R1's care, which were accommodated. Staff provided examples, such as the kitchen staff being asked to make a fresh fruit smoothie (no frozen fruit) for R1 each morning per request, specific staff being requested to administer coconut oil on R1's hair and braid it daily, ensuring R1 was placed in specific positions at certain time of day with pillows and stuffed animals strategically placed under a specific arm. Staff additionally informed that R1's representative also made unreasonable requests such as requesting a staff member's birthday be celebrated on a different day than R1, even though their birthdays were on the same day and the facility had a longstanding tradition of creating facility-wide events for all resident and staff birthdays. Staff informed that R1's representative called the facility approximately 3-4 times per day for status updates and to make requests for R1's care, and additionally called them on their personal cell phones when they were not on shift. Staff members consistently stated that inquiries from R1's representative were responded to promptly. (Continued on LIC9099 p. 4) (Continued from LIC9099 p.3) An independent investigation was conducted by an outside source protective agency. The outside source (OS1) informed that their investigation did not produce evidence that R1's representative was not responded to timely. OS1 informed that the representative was demanding and difficult to please. A second outside source familiar with R1 informed that the representative asked a lot from the facility and was very pushy, calling continuously. The outside source informed that it may have been a matter of misperception regarding the level of response from the facility. Records review revealed communication between R1's representative and the facility via care letter with a timeline of specific care needs and requests made by the representative that had been accommodated by the facility. Text messages between the representative and facility staff also showed the facility's responsiveness to the representative's requests. The investigation did not evidence that staff did not respond promptly to R1's representative's requests. It was alleged that staff did not have proper training to administer medications. Staff interviews revealed that the staff in question had the required training in place before administering medication. The staff in question informed that they were trained by a pharmacy at a different facility, and completed their training at this facility by shadowing and being observed by tenured medication technicians. Management confirmed that the staff in question had the required training prior to passing medications, and provided the staff's medication training credentials. Records review corroborated staff statements regarding the staff member's training, a completion certificate revealing that the staff member completed an 8-hour medication training with a pharmacy on 02/28/2024. Onboarding training documents showed that the staff member completed additional medication training specific to Dementia residents. The investigation did not evidence that the staff in question was not trained for medication administration, per requirement. R1 was unable to be interviewed due to no longer living at the facility. Records review and interviews showed that R1 was non-verbal and suffered from a major neurocognitive disorder, resulting in them being an invalid historian. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Marketing Manager Maria Flores, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.