Complaint Investigation Report

Allegation: Staff does not administer residents medication as prescribed

On 02/19/2025 LPA and LPM conducted a medication audit for three (3) residents. Resident #1 (R1) did have a discontinued medication with their currents meds but it has not been given to the resident since it was discontinued. Additionally, R1 was out of a medication but the facility is waiting for the refill.Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Lack of care and supervision resulting in residents sustaining multiple falls

During the course of the investigation LPAs interviewed facility staff. Interviews with staff revealed that the facility does have a handful of residents who are a fall risk. All staff are aware of which residents are a fall risk as well as their care needs. LPA reviewed all Unusual Incidents Reports (UIRs) regarding falls from May 2024 to September 2024. LPA found no discrepancies with falls and that the facility documented the falls as required with follow ups as necessary. Additionally, LPA reviewed the Post Fall Evaluation for six (6) residents. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility is not following food preparation safety procedures

On 05/22/2024 LPA Ratajczak and LPA Hiratsuka conducted staff interviews which indicated staff are trained on proper food preparation procedures. On 02/19/2025 LPA and LPM conducted a tour of the facility kitchen. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff serve expired and spoiled food to residents in care

On 05/22/2024 LPA Ratajczak and LPA Hiratsuka conducted staff interviews. Staff interviews indicated they have not observed any expired or spoiled food. Additionally, 02/19/2025 LPA and LPM conducted a tour of the facility kitchen, which included looking at facilities perishable and non- perishable foods. LPA and LPM did not observed any spoiled or expired food. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of the report and appeal rights was left at the facility.