complaint·November 18, 2024

CONTINUED FROM FORM LIC809-A Regarding the allegation that Facility staff are not ensuring that medications are inaccessible to residents , the following has been concluded: During both unannounced facility visits, the two medication carts in use by facility staff were actively observed to be stationed at the med tech station in the facility and verified to be locked. No other medication was observed to be accessible outside of the secure central storage. Regarding the allegation that Facility staff are not ensuring that residents are taking medications as prescribed , the following has been concluded: The facility uses an electronic medication administration records. Facility staff demonstrated the use of the software to keep track of prescription and administration status during the present visit. LPA additionally verified that there were no discrepancies between the centrally stored medication and the records for four randomly selected residents. No discrepancies or administration errors were found during the review. Regarding the allegation that Facility staff are not meeting incontinence care needs of residents , the following has been concluded: Based on residents and staff interviews, facility observation and review of records conducted during the two facility visits, no instances of wet/dirty linen or articles of clothing were observed. There were also no occurrences of any lingering smells that could be associated with a failure to manage incontinence symptoms in residents during the visits. Individual care assignments for the previous two weeks were also obtained and reviewed and confirmed that adequate incontinence care is being provided and documented by staff. As a result, the three allegations listed are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC809 Regarding the allegation that Unqualified facility staff are administering injections to residents , the following has been concluded: Based on records reviewed, multiple residents admitted to the facility are diagnosed with insulin-dependent diabetes while also being assessed to be unable to self-monitor their glucose levels or self-inject insulin if necessary. The stated facility policy is to conduct hand over hand glucose monitoring and injections, however based on multiple staff and resident statements, injections are often conducted single-handedly by facility med techs. Title 22 restrictions for admission and retainer of residents with diabetes states that the facility may admit or retain residents with diabetes " if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional ". Based on statements made during the visit, the restrictions are not met, therefore the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued on an attached form LIC809-D. An exit interview was conducted and a copy of this report along with attached citation and appeal rights were provided to a facility representative.