complaint·November 9, 2023

It was reported that the facility Staff are not ensuring the resident is taking medication as prescribed . To investigate this allegation, LPAs conducted an interview with Licensee, Designee and S1. All parties informed LPAs that four (4) out of four (4) residents receive their medications as prescribed and every time the medication is given to the resident, facility staff initials it on a Medication Administration Record (MAR). In addition, LPAs conducted interviews with four (4) out of four (4) residents and all residents confirmed that they receive their medications as prescribed. During today's visit, LPAs reviewed the facility Centrally Stored Medication and Destruction Record (CSMDR) of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPAs observed that two(2) out of two (2) randomly chosen prescribed medications were centrally stored by the facility, however, they were not properly documented on CSMDR. LPAs observed R2’s two (2) medications (Divalproex Sodium and Lithium Carbonate) were prescribed to be administered/given as of 11/01/23, however, both medications were not delivered/received by the facility. Moreover, interview with the Licensee, Designee and S1 confirmed that after acknowledging that the medications were not received, the facility did not report to the Pharmacy, Hospice Agency, Doctor, etc. regarding this matter. Although, two medications were prescribed to R2 as of 11/01/23, LPAs confirmed during todays visit, that R2 missed nine (9) days of prescribed medications, which poses a immediate health and safety risk to residents in care. Based on inspection, record reviews and interviews this allegation is deemed Substantiated. Deficiency cited on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered. It was reported that the facility Staff do not clean residents room. To investigated this allegation, LPAs conducted an interview with Staff #1 (S1) and were informed that on a daily bases the rooms are cleaned by taking out the trash, fixing the bed (change sheets if needed), dusting and organizing the room. A deep clean is also done on a daily bases, which includes vacuuming the room, cleaning the bathroom, changing the bed sheets, and any other maintenance the room may require. At 10:30am, LPAs toured resident rooms #2, #3 and #4. All the rooms appeared to be clean and free of debris. The rooms appeared to be lived in and they were well maintained. Interviews with four (4) out of four (4) residents confirmed that their rooms are being cleaned daily. Based on interviews and LPAs observation, there is not enough evidence to support the above allegation. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of this report signed and delivered.