complaint·April 3, 2025

It was discovered through observations, that on 04/03/2025 Administrator and LPA conducted a medication audit and reviewed medications of R1 and R2. LPA noted that medications for R1 were stored in both bottle and bubble pack storage from the pharmacy. R1’s bottled storage was prescribed before his admission to the facility and was still current by the Physicians prescription requirements. The remainder of R1’s medications were stored in bubble pack form from the pharmacy. R2’s medications were stored in bubble pack form from the pharmacy. No irregularities were noted during the medication audit. No expired medication was present, and no medication labels were altered. On 04/03/2025, LPA Jeffries noted that 5 empty bubble packs were set aside as the medication had been administered as prescribed as medication cycle for those bubble packs had been exhausted on this day (04/03/2025) and were placed aside to be discarded. At this time there is not enough evidence to support the allegations of, “Staff does not ensure expired medications are properly discarded.” and “Staff does not ensure medications are properly labeled.” And is unsubstantiated at this time. As to the allegation of, “Staff does not ensure that medication records are properly maintained.” It was alleged that in March of 2025, that, “residents’ medications not being logged on the MAR sheet each day.” It was discovered through interviews and documentation review that on 04/03/2025, LPA Jeffries conducted an interview with Administrator who stated that medication training and shadow training indicates that staff dispensing medications to sign the Medication Administration Record (MAR) immediately after dispensing medication to Residents. On 04/03/2025, LPA Jeffries noted in the medication records audit that there were no abnormalities or missed medication logs observed. LPA Jeffries noted that MAR and Centrally Stored Medication Records (CSMR) are also free of error and free of discrepancies. At this time there is not enough evidence to support the allegation of, “Staff does not ensure that medication records are properly maintained.” and is unsubstantiated at this time. As to the allegation of, “Staff does not ensure food containers are properly labeled.” and “Staff does not ensure expired food is properly removed from the facility.” It was alleged that, “old food containers without dated labels on them in the fridge.” It was discovered through observation and interviews that on 04/03/2025 LPA Jeffries conducted observational investigation as to the content of all food stored and prepared at this facility and found no improperly stored food, no food with degradation of quality, no expired foods, or stored food at a damaging temperature. On 04/03/2025, LPA conducted interviews of S1 and S2 both indicated that the food served at the facility is always of high quality and if they need to they can discard spoiled, or damaged food as needed. CONTINUED on LIC9099-C On 04/03/2025, LPA Jeffries conducted interview with Residents 1-4.(R1, R2, R3, and R4) All residents had no complaints of the quality of food and have never been served spoiled or damaged foods. At this time there is not enough evidence to support the allegations of “Staff does not ensure food containers are properly labeled.” and “Staff does not ensure expired food is properly removed from the facility.” and is unsubstantiated at this time. As to the allegation of, “Staff does not ensure resident health care needs are being met.” It was alleged that in March of 2025, “one of the residents has shingles” and the licensee failed to get the resident proper treatment for health condition. It was discovered through interviews and documentation that on 04/03/2024, R2 has visited their primary care physician on 02/27/2025. 03/04/2025 and 03/27/2025 to specifically address the condition alleged in this allegation. On 04/03/2025, LPA Jeffries conducted an interview with Administrator who stated that R1 has visited their physician three times for assessment and treatment to the condition listed in this complaint allegation. On 04/03/2025 LPA reviewed R1’s full file documentation on medical documentation verifying that R1 has been seen by a medical professional on 02/27/2025. 03/04/2025 and 03/27/2025 and has had their health care needs being met. On 04/03/2025, LPA Jeffries conducted and interview with R2, who stated they feel safe in this facility, and they (facility) have helped with all needs medical and other. At this time there in not enough evidence to support the allegation of. “Staff does not ensure resident health care needs are being met.” And is unsubstantial at this time. As to the allegation of, “Licensee allows unqualified staff to dispense medications.” It was alleged that in March of 2025 that. “Care staff are not trained on dispensing medications to residents.” It was discovered through documentation and interviews that on 04/03/2025, LPA Jeffries conducted interviews with S1 and S2 who both stated that they have had several hours of medication administration training and shadowing. An interview on 04/03/2025 LPA conducted an interview with Administrator who stated that all staff get medication administration training but has S1 and S2 are the main medication technicians for dispensing medication at this facility. On 04/03/2025 LPA reviewed and collected documentation indicating that S1 and S2 have had required medication administration training to assist residents with daily medications. At this time there is not enough evidence to support the allegation of, “Licensee allows unqualified staff to dispense medications”. And is unsubstantiated at this time. Exit interview, report read, and report provided