Complaint Investigation Report

Interviews with 6 staff revealed residents are provided assistance promptly. Interviews with 7 residents revealed they are provided with medical attention as needed. Record reviewed indicated that on 2/13/25, 2/15/25, and 2/16/25 R1 was provided with pain medication per R1’s request, as prescribed by the physician. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation Staff did not comply with physician’s instructions for medications and care.

It is alleged that facility staff failed to discontinue R1’s high blood pressure medication due to low blood pressure concerns and that R1’s prescribed back brace was not provided. LPA reviewed facility records and observed documentation indicating that, on 01/30/2025 at 4:46 PM, facility staff received instructions from R1’s physician to hold R1’s blood pressure medication due to R1’s low blood pressure condition. Additionally, the LPA reviewed R1’s medication list, which indicated that Amlodipine Besylate 5 mg was placed on hold effective 02/11/2025. Regarding the use of back braces, records reviewed confirmed that R1 was using the prescribed back brace. Facility notes indicate that a back brace was received on 2/12/25 and that a back brace was observed on R1 on 2/14/25. The Administrator stated that a Home Health nurse provided training to facility staff regarding proper assistance with the brace. Interviews conducted with 7 residents stated they receive assistance with medications or doctor’s recommendations as prescribed. Interviews conducted with 6 staff revealed that they assisted as the physician prescribed. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding allegation: Facility did not ensure appropriate communication with the resident’s responsible person and Staff did not report observed changes in resident’s condition.

It is alleged that facility staff did not communicate with R1's responsible party regarding R1’s needs and that facility staff did not report observation of R1 being lethargic. Interview with 6 staff stated that responsible parties are always notified regarding any changes in the condition of the residents and or any incidents that occurred. Interview with 7 Residents revealed that staff notifies their responsible parties regarding any change in condition or any incidents that occur. Record review indicated that on multiple occasions, R1's responsible party was notified. Facility’s internal notes review indicated that on October 2, 2024, R1 was observed to be lethargic, facility staff had called paramedics and R1's responsible party. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of this report signed and delivered.