complaint·September 16, 2021

Witness 1 (W1) stated W1 knocked on door and the staff answered the door not wearing a mask. Based on evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator. Residents are non-ambulatory and can not get up without assistance from staff. LPA explained that centrally stored medication needs to be kept locked and based on a residents LIC. 602 Physicians report if the box 14 j is marked YES then residents would need those items to be inaccessible. S2's interview revealed that S2 had medications out in the office on 09/08/2021 to prepare for residents when their was a knock on the door S2 answered the door leaving the medications in the office. Residents were in their rooms, are non-ambulatory and did not have access to the medications. Based on the evidence in this allegation it is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to Administrator/Licensee.