Complaint·September 11, 2024

According to the same statement that RP provided, the facility did make a note about the occurrence on May 19, 2023, when they found R1 that way. They have banned the resident assistant that was supposed to help R1 that night. Based on records review, the facility provided the LPA with Progress Notes. In these progress notes, the facility was already observing R1’s changes in conditions. A new assessment was done on April 27, 2023. In this assessment, it was noted that R1 is at risk for injury which may cause permanent disability or be life threatening. The following interventions/practices are recommended to enhance the safety of your family member. Reminders to use call system for needed assistance. Also in these progress notes from April 2023 – May 2023, it is noted in several entries that R1 has been eating less and less and has been experiencing pain and was being monitored continuously. R1 was entered into hospice on May 24, 2023. Regarding the allegation of Staff are not following medication orders, RP observed two of the medication technicians did not follow the orders. One staff member (S1) brought a 5 mg Valium and called it a hydrochlorothiazide. Another medication technician (S2) brought a whole Vicodin when the orders were to crush it into applesauce, but S2 brought the entire pill. Based on records review in the progress notes, on 05/23/2023 9:48AM (Late Entry) states that R1s family member (F1) gave R1 a Vicodin medication and is not on R1s med list. R1s MD was faxed, and a staff member (S3) is aware and R1 will be monitored for any allergic reactions or behavior changes. LPA was also able to obtain this report. Regarding the allegation that Facility is not safeguarding resident's personal belongings, RP stated that there is also a thief there that stole from R1 in December when R1 first moved in, a very valuable diamond ring and then on R1s deathbed, gold chain with charms. LPA spoke to the Executive Director (ED), and it was stated that the facility did an internal investigation and did not find any proof that a staff stole the valuables. page 2 of 3 Regarding the allegation of Facility is not maintaining a comfortable temperature for residents in care, RP stated that they had to ask facility to put an air conditioner in and it took weeks even though RP offered to buy it. R1s room was 90° on Easter even though the thermostat was set on 50°. During the interview, ED mentioned that the facility has not reached that temperature. While the rooms don’t have air conditioning system, the facility does have portable aircons which they can provide to residents if requested. According to RP, although it took quite some time, the facility did provide air-conditioning in the room. Based on interviews & records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3