Complaint·March 20, 2024

Investigation revealed the following: Staff mismanaged resident’s medication , it is alleged that on 03/14/24, R1 was injected with another resident's medication. R1 allegedly receives medication from a blue pen and was given medication from an orange pen, which belongs to another resident. R1 did not realize until the injection was administered that it was the incorrect colored pen. R1 reported the incident to their nurse but was told by nurse that there was not an orange pen. R1 did not exhibit any side effects and refused to get checked. Interview conducted with Administrator Anna Rempel revealed that facility staff do not administer any injections to facility residents. She stated that facility staff properly administer resident medications at their appropriate prescribed times on a daily basis as well as properly document on resident medication administrator on each resident's MARs. Administrator stated that R1 is seen by a Home Health nurse who comes in once a day to administer their medication. She stated that R1 did report the incident to her and that she spoke to the nurse who stated that a mistake was not made. She stated that R1's vitals were immediately taken and there was no concern noted as well as R1 was observed and no side effects were noted. Interviews conducted with S1-3 revealed that they administer and give residents their medications daily as prescribed by the doctor. They stated that facility staff do not administer injections to any resident and stated that home health nurses come in to administer injections for certain residents. Interviews with 8 out of 9 clients revealed that they get their medications on time everyday and that staff make sure that they take their medications. 4 residents stated that a home health agency comes in to see them either once or twice a day to administer injections. They stated that facility staff do not administer injections to them. LPA interviewed Home Health nurse who denied that R1 was given another resident's medication. Home Health Agency nurse stated that R1 is the only resident at the facility seen by the nurse and that there were no mistakes made with the resident's medication on 03/14/24 or any other day. Home Health Agency nurse stated that R1 is seen once a day for medication administration. LPA review of R1-9s MARs revealed that medications are appropriately administered to residents. R1 stated that the incident only occurred once and that it was a home health nurse who made the alleged mistake and not a staff at the facility. R1 stated that they did not feel any unusual side effects after the alleged medication mistake occurred. Based on interviews conducted with facility staff, facility residents, and LPA review of documents there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff do not ensure special diet plans are followed for residents in care , it is alleged that the facility does not serve food to meet resident's dietary needs. Interviews conducted with facility staff revealed that the food that is served to residents does meets all residents dietary needs and stated that all servings include grains, protein, fruits and vegetables. Administrator stated that the menu is reviewed and approved by a registered dietician every month. The dietician reviews the menus to ensure that the meals that the facility is serving to residents that follow a special diet are meeting their daily dietary needs as well as the needs of all residents in care. Administrator stated that food is ordered twice a week for facility to ensure that the facility has a sufficient amount of food supply for all residents in care. Interviews conducted with 8 out of 9 residents revealed that they are satisfied with the food service provided at the facility. 8 out of 9 residents stated that the food is healthy and satisfying, they are served different food options and if they do not want what is on the menu they can request a different meal option. 3 residents who were interviewed stated that they follow a special diet due to a health condition and they stated that they are satisfied with the meals that are served at the facility and stated that all meals served are healthy, well balanced and meet their dietary needs and the facility provides healthy alternatives as well as sugar free options and items such as sugar free substitutes. 1 resident stated that they are not served meals that meet their dietary need and they are forced to eat what is served. LPA toured the facility kitchen and cafeteria and observed facility menu and residents having their lunch. LPA observed the lunch being served to be well balanced with a selection of fruits and vegetables. LPA observed that the daily menu is posted and reflects what will be served for that day and also observed that there was an adequate supply of food which consisted of 2-day perishables and 7-day non-perishables. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held. A copy of the report was provided to Assistant Administrator Anna Rempel.