Complaint·August 24, 2023

Allegation: Facility is not following resident care plan. The Department conducted a file review, it revealed R1 needed assistance with transfer based on needs and service plan from December 2022. The Department observed no notes and/or documentation regarding turning every two hours was observed in R1's care plan. Based on interviews conducted on 5/8/2023, facility staff stated there are no residents in care that required a two-hour turning. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights was provided. Allegation: Facility does not provide medication as prescribed. Based on LPA and LPM's medication audit conducted on 08/23/2023, the audit included comparing Medication Administration Records (MARs) with resident’s medications, medication start dates and physician’s orders. Additionally, LPM, with facility staff present, conducted a medication count of residents controlled medications. Based on the medication audit conducted, MARs showed PM staff did not sign that medications were administered to residents in rooms #1-47. Days of missing signatures ranged from 3-6 days from the date of inspection. A sample of resident’s medications were compared to the MAR signatures and the medication start dates. R1’s medications were reviewed and revealed that R1 had a medication ordered on 08/07/2023 which was to be given 3 times a day. Based on the medication count, facility staff failed to administer R1 16 doses of medication. R2’s medications were reviewed and revealed that R1 had a medication that started on 08/14/2023 which was to be given 2 times a day. Based on the medication count, facility staff failed to administer R2 9 doses of medication. LPM and LPA conducted the medication audit with the facility Administrator, Lacy Berry, and Regional Director, Robert Godfrey present. Based on the allegation, staff are mismanaging residents medication, the allegation is SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegations cited above are substantiated, but no deficiency will be as LPA substantiated the same allegation for complaint 25-AS-20220926150347 on 8/24/2023. Exit interview conducted, copy of report and appeal rights was provided to Administrator.