complaint·January 30, 2025

The Administrator was unable to provide medication records with S1’s credentials. Four out of four staff interviews indicated that the Executive Directors will assist with medication administration if assistance is needed. Five out of eight resident interviews indicated that the Executive Director has not assisted them with medication. Three out of eight resident interviews indicated that the Executive Director has assisted them with medication but has not made errors. Regarding the allegation “ Staff are not ensuring resident's medication is being administered as prescribed," based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Facility staff mismanaged residents’ medication," it is being alleged that Staff #9 and #10 took oxycodone and xanex from residents six months ago (in April 2024 or May 2024). Resident #1’s (R1) hydrocodone was filled 05/23/24 and the medication administration record shows distribution in May 2024. Interview with R1 indicated that R1 did not take this medication and hasn’t ran out. Resident #2’s (R2) hydrocodone was filled 03/21/24 and the medication administration revealed daily distribution in April 2024 and May 2024. Interview with R2 indicated that R2 ran out because staff did not refill the medication until R2 ran out. Resident #3’s (R3) hydrocodone was filled 01/11/24 and the facility does not have controlled medication count records. On 11/08/24, LPA observed 81 out of 90 tablets on hand for R3. Interview with R3 indicated that R3 has not ran out of medication. Resident #6’s hydrocodone was filled 05/20/24 and the facility does not have controlled medication count records. Interview with R6 indicated that medication is well stocked but the facility does not refill it on time. Resident #7’s (R7) hydrocodone was filled 05/06/24 and the controlled medication count revealed medication administration from 09/09/24 – 01/07/25. R7 indicated that medication runs out because it is not refilled in time. Interview with the Administrator indicated that the facility does not have controlled medication count from 05/06/24 – 09/08/24. Resident #8’s (R8) oxycodone was filled 05/14/2024 and the controlled medication count revealed medication administration from 05/28/24 – 12/07/24. Interview with the Administrator indicated that the facility does not have controlled medication count from 05/14/24 – 05/27/24. R8 indicated that R8 ran out in the past because the doctor only prescribed two week’s worth. Continue to LIC9099-C. Resident #10’s (R10) alprazolam/xanex was filled on 02/05/24 and the controlled medication count revealed medication administration from 05/29/24 – 10/07/24. Interview with the Administrator indicated that the facility does not have controlled medication count from 02/05/24 – 05/28/24. Interview with Staff #1 (S1) indicated S9 and S10 has not been in the facility since 2019 – 2020. MedTech Staff #3, #4, and #8 indicated medication has not came up short and they not met nor witnessed S9 and S10 administer medication . Regarding the allegation “ Facility staff mismanaged residents’ medication ," based on record review, observation, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Regarding the allegation "Facility staff are financially abusing residents," it is being alleged that Staff #9 (S9) and Staff #10 (S10) have been stealing money from the residents’ P &I funds. Interview with the Executive Director (S1) indicated S9 has not been in the building since COVID 2020 and S10 since August 2019. S1 indicated that money is given every Thursday after lunch and if a large lump sum is needed then a check is requested. S1 indicated that the Office Manager conducts this process. Record review revealed seven out of nine residents had a balance on their P & I ledger. Six out of the seven residents indicated they did not have issues with P&I funds. One resident had a $0.00 balance, one resident had a negative balance, and both indicated they did not have issues with their P & I funds. Two out of two staff interviews indicated they have not received resident complaints concerning P & I funds. Regarding the allegation “ Facility staff are financially abusing residents ," based on record review, observation, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Administrator Melissa Flores.