Complaint·January 31, 2025

On 01/31/25 LPA obtained copies of progress notes where it is Documented that physicians have been contacted regarding medication refusals. The investigation revealed the following: Allegation: Staff do not ensure medication is stored in originally received container. It is being alleged that staff are preparing medications several days in advance. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents interviewed denied the allegation above and reported meds are prepared in front of them by med room staff, 1 of 10 residents interviewed reported resident is provided with meds already in a med cup. On 01/23/25 LPA conducted a tour of the medication room and observed medications to be in their originally bottle or bubble packs. Allegation: Staff do not ensure the facility is free of insects. It is being alleged that there are roaches in the medication room. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 3 of 5 staff interviewed reported pet have been observed in the past, it was reported, and the med room was treated by pest control. 2 of 5 staff interviewed denied the allegation above. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 6 of 10 residents interviewed denied the allegation above, 4 residents interviewed reported pest has been observed in the past however, it was reported to maintenance treatment has been provided. On 01/23/25 LPA conducted a tour of the medication room and did not observe any signs of pest, and med room was clean. On 01/31/25 LPA reviewed the p est control reports for December 2024 and January 2025, it is documented that the pest control company is coming out every week to treat rooms where pet have been reported as well as common areas. Allegation: Staff mismanaged residents' medication. It is being alleged that staff are being instructed to give a resident a medication that belongs to another resident because the resident was out of a particular medication. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported there is an over flow of medications located in the med room to ensure a resident does not run out of medications. On 01/23/25 and 01/31/25 LPA conducted interviews with R1-R10, 9 of 10 residents denied the allegation above and reported they have not run out of medications. 1 of 10 residents interviewed reported running out of medications from Kaiser due to a payment mis-communication with family. On 01/23/25 LPA observed there is an over flow of medications for residents stored in med room cabinet. Over flow was observed to be organized and labeled with residents name. LPA reviewed in-service held and attended by all medroom staff dated 09/25/24 and 10/16/24 for ordering and documenting medications. Allegation: Staff are falsifying residents' medication administration record (MAR). It is being alleged that med techs are entering meds as given even when they don't administer it. On 01/23/25 and 01/31/25 LPA conducted interviews with ED, and S1-S4 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 4 of 5 staff interviewed reported MARs are documented in real time. On 01/23/25 LPA conducted a medication review for R1-R6, LPA did not observe any discrepancies on the MAR. 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. Exit interview conducted, and a copy of this report was provided.