1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | During this investigation at 1:40 pm, LPM Margaryan conducted a quick tour to the facility and observed no health and safety issues.
At 2:00pm, LPM and LPA spoke with three (3) staff members staff #1 (S1), staff #2 (S1) and staff #3 (S3) that had knowledge about R1’s care and supervision at the facility. At 2:40 pm, LPA spoke with five (5) facility residents, including Residnent'#1' (R1's) roommate and Resident #2 (R2).
In addition, LPA Comer, requested and reviewed facility records, including, but not limited to, R1’s physician report, medication administration and destruction records, incident reports involving R1, staff testimonials about R1, and other documents pertinent to investigation.
Allegation: Staff do not distribute resident's medication as prescribed.
It was alleged that R1’s medications, including patches, were not distributed to R1 as prescribed. Staff revealed that R1 does not follow facility medication administrator procedures and refuses to take their pills as prescribed. S1, who is a med tech assisting R1, revealed that R1 goes to the doctor, requests to change the dosage of medications, gets new orders from the pharmacy, and wants med techs to dispense a new order. When med tech explains that they need new prescription to change the order in the file, R1 gets upset, refuses the medication, yells at the staff and throws the med cup at them. Other residents interviewed during this visit, including R2, had no concerns regarding their medication assistance. R2 verified the information revealed by staff. A review of medication administration and destruction records corroborated the information received from the staff.
Based on interviews, and records review, there is not sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.
Allegation: Staff do not provide a safe environment for residents.
It was alleged that R1 was verbally and physically abused by Resident #3 (R3). R3 was harassing R1 by calling him names, and talking badly about R1’s mother. On 04/16/26, R3 tried to fight R1, but did not touch them. S2, who witnessed both incidents, denies R3 fighting R1, or calling them names. S3 revealed that R1 always tried to fight and yell at other residents and staff. R3 denied fighting R1, or calling names. R3 stated that R1 yelled at him and called him names. R3 stated while R3 was trying to leave the dining room, R1 blocked the entrance so that R3 was unable to go out. (R3 uses wheelchair to ambulate.)
LPA Comer attempted to speak with R1. However, they were not available. A review of collected records did not provide any information to support the allegation. |