complaint·October 4, 2022

LPA Colvin observed that despite staff's statement that PRN medication is given as often as stated on the prescription, there were not administrations of the PRN of Quetiapine Fumarate or notes of refusals for the month of September until the 20th, no administration Cetirizine in September 2022 or October 2022, and sporadic administration of PRNs Acetaminophen and Hydrozyzine. Additionally, LPA Colvin observed notes for Buspirone (9/1/22 - 9/21/22, 9/26/22 - 10/4/22) and multiple other medications for 10/1/22 through 10/3/22, which stated "Physically unable to take". LPA Colvin inquired with staff what this note means and staff stated that they did not have the medication for the resident and were waiting for a refill. LPA Colvin reviewed the Centrally Stored Medication Log which showed the medication refilled on 9/26/22, but staff stated that the date listed is not the date received, but the date the order for refill was placed with the pharmacy. LPA Colvin inquired about the missing doses for September, and staff stated that there were issues with getting the medication refilled as R1 had not seen their Primary Care Physician (PCP), and the prior prescriptions were from the hospital. It should be noted that Busporone is prescribed to be taken by the resident twice daily for agitation, and is not a PRN. Since the facility has not administered all of R1's medications according to physician's orders as noted above, the allegation " Staff did not provide medications to a resident while in care" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Executive Director Shannon Wilkerson during the exit interview. Regarding allegation " Staff stole a resident's personal belongings": LPA Colvin conducted interviews with staff, resident (R1), and others with knowledge of R1's possessions at the facility. LPA Colvin additionally reviewed R1's file regarding property listed in R1's possession at the facility. LPA Colvin learned through interview with one of R1's Power of Attorney's (POA) that one of the items of concern (tablet) was removed from R1's possession by order of the POA, and the facility has the tablet stored in the med room and available to R1 on request. LPA Colvin inquired about R1's reportedly missing "Alexa" device, but staff did not have knowledge of the device to be missing, though it is noted in R1's property log. While R1's device may have been misplaced by R1 or taken by another (possibly a resident), there is not enough evidence to confirm that R1's "Alexa" was taken specifically by a staff member. Additional items of concern (photos, perfume, makeup) were not listed on R1's property log and staff denied any knowledge of missing items. Therefore, based on record review, interviews, and lack of evidence, the allegation " Staff stole a resident's personal belongings" is UNSUBSTANTIATED. Regarding allegation " Staff inappropriately searched a resident while in care": LPA Colvin conducted interviews with staff, resident (R1), and others with knowledge of R1's care and history. LPA Colvin attempted to interview the suspected staff (S1) to have inappropriately searched R1, but S1 works the overnight shift at the facility, and did not respond to LPA Colvin's telephone call. Other interviews conducted did not reveal any supporting evidence to the allegation, and staff interviewed denied there being specific objects that R1 is not allowed to have, other than the standard sharp items, and that staff do not search residents. Therefore, due to lack of evidence and conflicting statements, the allegation " Staff inappropriately searched a resident while in care" is UNSUBSTANTIATED. Regarding allegation " Resident is being mistreated while in care": LPA Colvin interviewed staff, resident (R1), and others with knowledge of R1's care. The majority of interviews conducted with persons who had knowledge regarding the circumstances surrounding the allegation, provided LPA Colvin with a consistent story of events. The allegation is in regards to R1 being "isolated" in another building other than where R1's room is located. Interviews revealed that at some point after R1 was admitted to the facility in May 2022, R1 observed someone type in the security code for the doors to the building where R1 lives, and memorized the code. Staff was made aware of the security breach, and until the code could be reset, R1 was moved during R1's waking hours to the building next door for "Day Programming". LPA Colvin inquired as to what "Day Programming" consisted of, and was informed that it was simply moving R1 to the other building (which had a larger number of staff) during the waking hours for supervision purposes of R1. LPA Colvin confirmed with staff that R1 was returned to their building and their room at night so that they would be able to sleep in their bed. LPA Colvin additionally was informed by multiple persons interviewed that R1 has a history of making false allegations, and that R1 will lie about everyone and everything if it suits their needs/agenda. LPA Colvin observed that on R1's Physician's Report dated March 2022 that it was noted that R1 has delusions which R1 believes to be the truth. Therefore, due to lack of evidence suggesting that R1 was mistreated and multiple consistent interviews regarding need for additional security measures for R1, the allegation " Resident is being mistreated while in care" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with Executive Director Shannon Wilkerson and a copy of this report was provided.