complaint·April 11, 2025

Investigation revealed the following: Regarding the allegation, " Staff administered resident a suppository without a prescription ", it has been alleged that staff have provided a suppository without Dr.'s orders. LPA conducted record reviews of the changes in a resident's primary care physician, listed in order from oldest to newest: Dr. Anna Mellor (AM) from May 2015 (05/15) to March 2021 (03/21), Dr. Christopher Traughber (CT) from 03/21 to March 2025 (03/25), now Dr. Robert Reiss (RR) from 03/25 to current date (04/11/25). LPA reviewed a fax to RR, who ordered, and confirmed, the use of an over-the-counter (OTC) medication following a request from a resident's responsible person(s). RR only confirmed OTC, starting 03/26/25, and did not discontinue (DC) a suppository. LPA further reviewed the medication administration record (MAR) of a resident from the months of February, 2025 (02/25) to April, 2025 (04/25). During the dates in question, there has not been any marked dose of a suppository to a resident in care. On 04/11/25, between 09:00AM and 1:00PM, LPA interviewed eight (8) staff (S1-S8). Between 2:00PM and 4:00PM, LPA interviewed five (5) residents (R1-R5). All eight (8) staff interviewed (S1-S8) and five (5) out of five (5) residents interviewed (R1-R5) have denied the allegation has taken place, while witness one (1) is unsure whether the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . There have been no deficiencies cited during today's visit. An exit interview was held with staff one, Nicole Prescott Nurse Manager (S1), and a copy of this report has been provided.