It is being alleged that staff neglected to provide medication to R1. LPA Calderon toured the facility with S2. LPA walked into the medication room and noted residents taking their medications. LPA also noted staff in the dining room giving medications to residents. Reviewed the MAR (dated 08/2024) for R1. Per the admission agreement (dated 08/15/2024 R1 moved into the facility and per the MAR staff started to give medication to R1 starting on 08/16/2024. Reviewed Market Pharmacy order form (dated 08/22/2024), drug Lacrollmus, last office visits 08/21/2024, message from NewRx, “not covered prior authorization required. We already send paperwork to MD office, please follow up with MD”. 4 out of 4 staff indicate that R1 was provided medication on time. 2 out of 2 staff indicate that R1 medication for R1 liver was rejected by R1 insurance company. 6 out of 7 residents indicate no issues with staff giving medications. 6 out of 7 residents indicate staff have never run out of their medications.

Regarding Allegation #2: Staff did not ensure residents room was cleaned.

It is being alleged that staff did not clean R1 room. LPA Calderon toured the facility with S2. LPA inspected all common areas and all areas appeared to be clean. LPA noted staff cleaning rooms and common areas. LPA inspected room 3, 17, 36, 46, 65 (R1 room), 76 and 85. All rooms appeared to be clean, bathrooms were clean, and trash was picked up. Per R1 admission agreement (dated 08/15/2024) page 9 “staff will clean residents’ room weekly”. 4 out of 4 staff indicate that staff do clean residents’ room weekly. 6 out of 7 residents indicate that staff do clean their rooms weekly and pick up trash daily. 6 out of 7 residents indicate no issues with facility staff cleaning their rooms.

Regarding Allegation #3: Staff did not safeguard residents clothing.

It is being alleged that staff washed and damaged R1 clothes. LPA Calderon toured the facility with S2. LPA inspected the laundry room and noted residents wash being cleaned. LPA also noticed staff transporting folded clothes in a basket to resident’s room. Reviewed admission agreement (dated 08/15/2024) for R1. Per page 8 "states that laundry will be provided weekly". 4 out 4 staff indicate that there have been no complaints regarding staff washing residents’ clothes. 6 out of 7 residents indicate no issues with staff washing their clothes.

It is being alleged that the AC in R1 room was not working. LPA Calderon toured the facility with S2. LPA noted the AC working in the common areas. LPA inspected room 3, 36, 46, 65 (R1 room), 76 and 85. LPA noted that the AC was working in each room. 4 out of 4 staff indicate that there have been no issues with the AC unit and 4 out of 4 staff indicate that all AC units are working for each room. 6 out of 7 residents indicate that the AC in their room is working fine and they have no issues.

Regarding Allegation #5: Staff did not ensure the bathroom fan was not in disrepair.

It is being alleged that the bathroom fan in R1 room was not working. LPA Calderon toured the facility with S2. LPA inspected room 3, 17, 36, 46, 65 (R1 room), 76 and 85. LPA noted the fan in each bathroom and bedroom fan was working. 4 out of 4 staff indicate that all bathroom fans are working, and no complaints have been made. 6 out of 7 residents indicate that the bathroom fan in their room work fine and they have no issues.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff are mismanaging residents medication”, “staff did not ensure residents room was cleaned”, “staff did not safeguard residents clothing”, “staff did not ensure the AC was not in disrepair”, “staff did not ensure the bathroom fan was not in disrepair” is found to be UNSUBSTANTIATED.