complaint·August 1, 2025

Allegation: Staff did not ensure centrally stored medication was locked and inaccessible to residents. It has been alleged that staff misplace residents’ medication which would later be found inside the residents’ rooms. Staff interviews revealed that residents medications are locked inside a medication cart which is stored inside the locked medication room. Interviewed staff indicated that residents’ medications are not misplaced nor later found in residents’ rooms. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide residents with their medication daily and in a timely manner. Interviewed residents indicated that staff provide supervision when medication is provided to ensure the medication is consumed by the resident. Interviewed residents indicated that they do not have direct access to medication as the medication is centrally stored inside a medication cart and is inaccessible to residents. Interviews do not corroborate this allegation. Allegation: Staff falsified medication records. It has been alleged that staff misplaced a R-1’s Oxycodone pill and rather than reporting the pill missing, staff allegedly “falsely reporting it as a miscount”. Staff interviews revealed that on 04/26/25, R-1's Oxycodone pill #16 was discovered inside the medication cart and not inside the bubble pack. Interviewed staff indicated that the foil of R-1's bubble pack for Oxycodone somehow was broken/punctured under pill #16 which caused it to fall out of the medication bubble pack and onto the medication cart. Staff interviews revealed that R-1’s Oxycodone pill #16 medication was not missing as it was found inside the medication cart, therefore, per staff interviews, this medication was not reported as a “miscount”. Interviewed staff indicated that controlled medications are counted by staff on a daily basis and are logged on the controlled medication shift count. Interviewed staff indicated that R-1 takes this medication on an as needed basis and the last administration was on 03/16/25. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Interviews and reviewed documentation do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff did not provide adequate supervision resulting in resident missing their medication dosage. It has been alleged that staff dispensed a diabetic medication to a resident (R-2) but did not ensure that the resident (R-2) consumed it and left the room. Staff interviews revealed that staff provide adequate supervision when administering residents’ medication. Interviewed staff indicated that R-2 takes their medication in front of the medication technician. Interviewed staff indicated that they have not found any unconsumed medication inside R-2’s room. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff administrating medication provide supervision to residents during the medication distribution to ensure residents are consuming their medication. Interviewed residents indicated that staff do not just provide them with their medication and leave. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Allegation: Staff left residents in soiled diapers for extended periods of time It has been alleged that staff avoided changing residents’ briefs at the end of their shift and that residents were wet, soiled and waited an additional hour and a half to be changed. Staff interviews revealed that staff do not leave residents in soiled diapers for extended periods of time. Interviewed staff indicated that they conduct rounds every (2) hours and as needed to change residents with soiled diapers. Interviewed staff indicated that they do not wait until the end of their shift to change residents’ diapers nor wait an hour and a half to change residents' diapers. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide incontinence care in a timely manner. Interviewed residents indicated that staff do not leave them in soiled diapers for an extended period of time. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. 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. Exit interview conducted and a copy of this report and appeal rights were provided to Adriane Runge (Executive Director).