Complaint Investigation Report

Regarding the allegation "Staff did not ensure that resident received prescribed medications" it was alleged Resident #1 (R1) did not receive their medication for a few days. Interview with the administrator at 2:30 p.m. on 11/19/25 revealed most residents switched to a new pharmacy on 10/01/25. Review of R1’s physician orders revealed their medications were scheduled to be refilled on 09/30/25. Review of R1’s MAR revealed they did not receive two (02) medications on the evening of 09/30/25 and six (06) medications on the morning of 10/01 due to “pending pharmacy delivery”. The administrator also said they drove to the pharmacy at 8:00 p.m. on 10/01/25 for R1’s medication refill. The issue with the pharmacy was worked out. Interviews with Staff #4 (S4) at approximately 10:15 a.m. on 12/02/25 and Staff #5 (S5) at 2:30 p.m. on 01/09/26 confirmed R1 was not assisted with bedtime medications on 09/30/25 and morning medications on 10/01/25 due to running out of supply. Review of R1’s physician report and admission agreement revealed they could not handle their own medications and relied on the facility for medication assistance. Based on interviews and record review, staff did not ensure R1 received prescribed medication for at least two (02) doses. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page.

Regarding the allegation "Staff are using dirty kitchen appliances to prepare meals" it was alleged the facility prepared toast for R1 on a grill which was used to cook bacon. Interview with the head chef, Staff #3 (S3) at 12:15 p.m. on 11/19/25 revealed the toaster was in disrepair for about one (01) day. S3 confirmed toast was made for all residents on the same grill used to cook bacon. During facility tour on 11/19/25, LPA observed two (02) toasters in the kitchen. Interview with the administrator at 2:30 p.m. on 11/19/25 revealed the facility purchased multiple toasters to resolve the issue. Based on interviews and observations, the facility toaster went into disrepair, so staff cooked toast on the grill and replaced the toaster the next day. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page.

No immediate health or safety concerns observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.