Complaint Investigation Report

On the allegations Facility is in disrepair, Staff are not following the residents care plan

Facility does not send incident reports as required, and Staff are not providing medication as prescribed the following was found. On 12/09/2024 When ED was interviewed the LPA found the following. ED states that when they came in they felt like the facility was not lacking in sanitation and cleanliness in their opinion. However ED did acknowledge that prior to their on boarding the center elevator was down for about a month and a half. The ED states that they just discovered that one of the fireplaces is not operational last week when putting up Christmas decorations. ED states that they are aware of the dryers and washers being out of service but they are not aware of how long they have been out of service. ED stated that they are actively trying to get new carpets but will not know if it is approved by upper management. ED states that the prior Health and Wellness Director (HWD) would change the residents needs and services and that they would receive the care but that the families were not aware of the cost associated with the care. The ED states that because of the discrepancy they have reimbursed credits. ED states that HWD resigned when confronted with the discrepancy. It was also found before the HWD resigned that reports were not being reported as required. ED states that there were instances where residents care plan did not match the care they needed or did not require.

On 4/23/2025 LPA reviewed files and interviewed S1 and S2 and found the following: LPA observed that there were multiple instances on R1 MAR where medication was marked as administered however R1 was out of the community and unable to have taken the medicine. LPA identified that S1 made the error and found the following in the interview. S1 states that they pre pour medication based on the med list and then hand them out. After hand out they get marked off. S1 states it might have just been a mistake that medication was marked as given when it had not been administered. LPA then spoke with S2 to understand more about how a medication error like this could occur. S2 stated that the system where med-techs have to mark the medications given needs to be pressed twice to reflect not administered or else the system will mark as medication given. They believe that the medication being marked as given was an oversight.