complaint·September 21, 2023

Allegation - Staff did not distribute resident's medication as prescribed. It was alleged that the facility was administering medications that were discontinued to Resident #1 (R-1). LPA reviewed the physician’s order form provided to the facility by the hospice agency upon admission on 12/1/22. The medications listed on the facility's medication administration record (MAR) was also reviewed and it did not appear to have any discrepancies. The facility also had physician orders for any new medications that were prescribed after admission. Per interviews with staff, R-1 was overall compliant with the medications. Staff had initialed the MAR logs when resident took the medication and/or indicated the reason for not. R-1 had moved out of the facility on 12/28/22. Allegation - Staff did not meet resident's incontinence needs. LPA interviewed Staff and Residents. The administrator stated that staff check the resident’s diaper every 2 to 3 hours and change as needed. The caregiver will log down if there is a bowel movement. Staff indicated they would check the resident’s diaper a few times during their shifts and change when needed. They do not keep residents in soiled diapers. 3 out of the 4 residents interviewed stated that staff check their diapers and change them if needed. One is able to change it himself/herself but staff would also check on them. Allegation - Staff did not assist resident with showering. It was alleged that staff did not shower or wash R-1’s hair regularly which caused R-1 to smell bad. The administrator and staff interviewed stated the residents are showered daily. Those on hospice care receive showers through outside personnel, however, facility staff would also provide showers on the other days. Staff stated that R-1 was showered often when allowed, either by the hospice personnel or facility staff. LPA interviewed 4 residents who all stated they get showers frequently. 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. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.