Complaint·February 24, 2025

Regarding the allegation, staff did not dispense medication to a resident as prescribed, according to the reporting party, when R1 arrived at the facility on 10/17/24, staff did not dispense R1’s evening medications or morning medications the next day. During the investigation, LPA reviewed documents provided by the facility and interviewed the administrator. The administrator denied the allegation and indicated that R1’s family did not provide medications to the facility when R1 moved in and the facility had to order the medications through the pharmacy, however the pharmacy was unable to deliver all the medications timely. Based on the QMAR reviewed, the facility noted that some of the medications were not available at the facility, however the ones that the pharmacy delivered were provided to R1. In addition, based on R1's care notes, it was noted that the facility called the pharmacy on 10/17/24 to re-order all of R1's medications, however the pharmacy was only able to deliver some of the R1's medications on 10/18/24 in the morning. Regarding the allegation, Licensee did not ensure resident’s bathroom was in good repair, according to the reporting party, R1’s toilet tank was missing completely. During the investigation, LPA observed the toilet tank in good repair and fixed in the room R1 used to stay in. LPA reviewed a receipt from the administrator that indicated, on 10/24/24 a new toilet was purchased and replaced on the same day. LPA confirmed with the Maintenance Director that the toilet was fixed the same day it was bought. Regarding the allegation, staff did not ensure resident was provided with adequate bed linens, according to the reporting party, R1’s family provided sheets to R1 but during a visit on 10/26/24, it was observed that R1 did not have any linens and staff indicated that the linens were being washed. During the investigation, LPA interviewed administrator and staff and observed 5 resident rooms. LPA observed all rooms to have bed linens. Based on interviews with housekeeping staff, it was indicated that bed linens are provided by family and staff wash them once a week or as needed. Regarding the allegation, staff did not ensure resident was provided postural supports, according to the reporting party, R1 was noted to be a fall risk, however the facility did not provide any equipment to prevents falls such as grip bars or slip-resistant mats. (Continue to 9099C) During the investigation, LPA reviewed R1's file and interviewed the administrator. Based on R1's physician's report, R1 is noted to be non-ambulatory and the service plan indicates R1 will ambulate independently throughout the community. Based on administrator interviews, R1 was not at fall risk and the facility is not a medical facility where postural supports are provided by the facility. According to interviewed staff, the facility does have non-skid mats that staff will put in residents showers before giving residents a shower. Based on observations, documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.