complaint·March 6, 2024

Resident tested positive for a controlled substance which is not a prescribed medication. On 12/7/2023, R1 was taken to the hospital with a chief complaint noted to be “confusion.” While R1 was at the hospital, a urine test was completed, and the results came back showing R1 tested positive for Fentanyl and amphetamine. R1’s prescribed medications list did not include Fentanyl or amphetamine. During the investigation, it was learned R1 is taking a medication called Wellbutrin. Per Hospital medical records, Wellbutrin can cause a false positive for amphetamines. The Director of Nursing and staff stated Folsom Countryhouse does not have any residents who have prescriptions for Fentanyl or amphetamines. Facility staff did not know how R1 tested positive for both Fentanyl and amphetamine. Medication Technicians reported that the medication room and medication cart are both locked, and they stated that the medication room or medication cart has never been left unlocked. Staff were asked if there were any concerns about staff using Fentanyl or amphetamines within Folsom Countryhouse and they said no. Residents were interviewed and had no complaints to report. Through interviews and record review, the Department could not find substantial evidence to support that the allegation occurred. The Department finds this allegation to be UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report was left with Director of Nursing Brian Pawloski .