complaint·July 22, 2025

(Continued from 9099) The complaint alleges that Staff do not ensure care needs of residents are being met. The complainant states that there are only 2 caregivers assigned. Regulations for CCL do not require a ratio between care staff and residents. LPA reviewed facility records and found 3 care staff and one medtech scheduled to work in the memory care unit for the AM and PM shift. LPA observed the facility on multiple occasions (3/11/25, 4/1/25, 4/7/25,5/29/2025, 7/17/25, 7/22/2025) and found the facility to be clean and the residents to be clean and dressed appropriately. LPA observed lunches being served and activities (manicures, Trivia, Bingo, Uno, Art/Coloring) and found residents to be assisted as needed. LPA reviewed a sample of 5 of 28 residents’ care/service plans and found residents care plans were recently updated to meet the residents’ needs. According to staff (S1), incontinence care is not charted but staff have a schedule to ensure residents are receiving two-hour checks and continence care. In addition, according to statements by staff member (S1) residents who are in their rooms receive additional safety and continence/re-positioning care (like for those receiving hospice services). Based on observation of residents, sampling of resident weight records and resident interviews (4 of 28 residents in Memory Care) the allegation that Staff do not ensure care needs of residents are being met is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated. The complaint alleges Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed. The complainant states various caregivers are assigned medtech duties who are not qualified and they are dishonest about distribution of meds. LPA reviewed staff training documentation which shows that staff employed as medication technicians receive training and are tested to verify their knowledge. Also, licensed LVNs and RNs are employed to supervise care and administer insulin injections to those residents requiring per physician’s orders. LPA reviewed medication records of residents receiving insulin and found that the insulin was administered per doctor’s instructions by a licensed professional/LVN/RN. (Continued on 9099-C2) (Continued from 9099-C) In addition, Medication Administration Records (MARs) were inspected and found to be completed. LPA performed an inspection of random medications pulled from the medication room in Memory Care and 5 out of 5 were accurate. Based on the review of MARs, medications, training records and inspection of professional licenses the allegation that Licensee allows unqualified staff to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated. Although the allegations may have happened there is not a preponderance of evidence to verify the allegations therefore, the allegations that unqualified staff are allowed to dispense medication and Staff do not ensure medications are dispensed as prescribed are unsubstantiated.