complaint·September 20, 2024

Allegation: Staff are not administering medications as prescribed. It is alleged that medication technicians were not refilling medications in a timely manner, pills were being popped but not given to residents, or the pills were not popped at all during the months of May 2024- June 2024. Information obtained alleges that there were at least 10 residents that were not receiving medications as directed by their physicians. Staff interviews revealed that the facility has been experiencing issues with medication technicians during the last 4- 6 months, because med-tech's were not fulfilling their job responsibilities i.e., documenting on the electronic Medication Administration Record (MAR) that the medications were dispensed, or calling for refills with advance notice. Staff stated medications were being administered but there were MAR errors, and lack of documentation on the MAR to prove staff dispensed the medications. A total of 8 residents were interviewed, none reported knowledge of inappropriate dispensing of medications. However, per record review of Medication Administration Records (MAR) of 10 residents, the findings indicate that multiple residents went days without medication administration by med-tech staff. The lack of documentation was observed in all shifts. There is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided. Allegation: Lack of supervision resulted in residents assaulting other residents in care . It is alleged that the facility is failing to ensure the health and safety of residents because residents have been sexually assaulted by resident(s). According to information obtained, management staff have knowledge that there is a known registered sexual offender residing at the facility and were made aware of incidents of sexual inappropriateness by resident (R1) towards resident (R2), and possibly towards resident (R3). Additionally, another resident (R4) allegedly verbally assaults residents with sexual comments and conducts themselves in an inappropriate manner towards staff. It was reported that R1 was observed entering the room of a cognitively impaired, non-ambulatory resident. A total of seven (7) staff were interviewed, of which none reported knowledge of suspected sexual assaults towards residents by R1 or R4. Staff stated they have not observed R1 & R4 act inappropriately with other residents. However, all staff stated that R4, has cognitive impairment and frequently says sexual comments to female staff, but stated none of the residents have reported sexual inappropriateness or assault. A total of 8 residents were interviewed, of which all denied the allegation. Residents (R1 & R2) denied the allegation. There is insufficient evidence to corroborate the allegation. 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, therefore the allegation is Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Diana Bautista.