complaint·July 3, 2024

Staff #2 (S2) stated insulin is not refilled every month by corresponding with the primary care physician or the pharmacy, rather it is on a cycle and routinely refilled without anyone having to request for a refill and at no time did the resident not have access to or receive insulin. S2 stated resident was admitted to the facility on 06/02/2023 and received the first dose at the facility on 06/03/2023. S2 added that the insulin R1 was admitted to the facility with was a two (02) month supply and lasted until the first refill on 08/02/2023. During interviews with residents, all residents stated their medications are refilled in a timely manner. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not dispense medication to resident as prescribed. It was alleged that Resident #1 (R1) is to take insulin three (03) times a day but it was not dispensed as prescribed. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. On 07/03/2024, LPA Duguma requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. A review of R1’s prescription documents indicate a change in dosage from three (03) times a day to once a day before bedtime. A review of the Medication Administration Record indicates that R1 self administered the insulin at 9:00 PM. During interviews with staff, all staff stated residents are dispensed medications as prescribed. During interviews with residents, all residents stated their medications are dispensed as prescribed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not prevent residents from smoking in non-smoking areas. It was alleged that the facility’s hallways smell like marijuana and R1’s roommate smokes cigarettes in the room. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. (CONT on LIC 9099-C) On 07/03/2024, LPA Duguma conducted a physical plant tour and requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. During the physical plant tour, LPA did not experience any marijuana or cigarette odor throughout the facility. During interviews with staff, all staff stated residents do not smoke marijuana or cigarettes in the facility and are not aware of R1’s roommate smoking cigarettes in their room. During interviews with residents, all residents stated they are not aware of marijuana or cigarettes being smoked anywhere in the facility. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.