Complaint·April 15, 2022

LPA Tryon arrived at the facility unannounced on 4/15/2022 at 11:00 a.m. to continue to work on the complaint. LPA was screened at the door for COVID symptoms, temperature taken. LPA used hand sanitizer and wore a surgical mask. LPA has spoken with both current and former Executive Directors, interviewed staff, interviewed 5 residents, reviewed documentation. Regarding the allegation taht untrained individuals are administering medications to residents, CCL staff has interviewed former ED and staff. LPAs learned that the facility was using temporary staff from agencies quite a bit over the past couple of years. LPA learned that on several occassions the temporary agency staff was asked to pass medications to residents. The former ED stated to CCL staff that she did not verify that the agency staff had done medication training, as the agency does their own training. So, although the agency staff may or may not have had medication training, there is no written documentation to prove it. Therefore, since it cannot be proven, the allegation is SUBSTANTIATED. A finding that the allegation is substantiated means that the preponderance of the evidence standard has been met. The following deficiency is issued as per Title 22 Regulations. Appeal rights provided, exit interview conducted.