Complaint·December 11, 2024

Regarding Allegation #1: Staff does not abide by the admission agreement. It is being alleged that staff did not follow the admission agreement for R1. CCLD staff toured the facility and noted residents making a line for medications around 11:30 am. CCLD staff reviewed the admission agreement (date 04/04/2024), page 2 “assistance with taking prescribed and over the counter medications”, VA care plan (date 04/02/2024) page 6 “residential care facilities are required to assist residents with self-administration of medications as needed”, MAR (date July to December 2024), all medications were given to R1 no errors were made. 3 out of 3 staff indicate that all staff follow the admission agreement for R1. 3 out of 3 staff indicate that medications are given to residents 3 to 4 times a day as prescribed by resident’s doctor. R1 indicates that staff do not follow the admission agreement he signed and do not give medication to R1 when needed. 6 out of 7 residents indicate that staff does follow the admission agreements. 6 out of 7 residents indicate that staff serves 3 meals per day and gives medications 3 or 4 times per day. Regarding Allegation #2: Staff mismanaging residents’ injections. It is being alleged that staff did not give R1 injection when prescribed. CCLD staff toured the facility and noted residents lining up for medications around 11:30 am. Reviewed MAR (date July to December 2024). VA notes suggest that injection was new and did not arrive until 08/28/2024. MAR indicates that all medications were given to R1 and R1 signed for self-injection medication from (October to November 2024), needs and service plan (date 04/04/2024), R1 has health issues. S2 indicates that all injections are self-administrated by R1. S2 indicates that R1 moved into facility on 04/04/2024 and that injections started on 08/28/2024. S2 indicates that staff gave R1 all medications that are prescribed and update R1 MAR. R1 signed for injections from October to November 2024. S2 indicates that no staff would inject R1 without a RN or LVN. S2 indicates that from April to September 2024 staff gave medications to R1, then R1 took over medications from September to November 2024 when VA made changes so that facility staff took over in December 2024 giving medications to R1. 3 out of 3 staff indicate that R1 did not have any injections until August 2024. R1 indicates that R1 only received 1 injection for 2024. 6 out of 7 residents indicate that all medications are given to them 3 to 4 times per day. 6 out of 7 residents indicate no injections are given to them as part of their medication list. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “staff does not abide by admission agreement”, “staff mismanaging residents injections” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Mark Ingber S1.