Complaint·October 24, 2023

It was learned that (R1) had medication for Quetiapine Fumarate, 25 MG and the medication was not on (R1) MAR sheet; therefore, it is unclear if (R1) received the medication. The investigation also revealed that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was incorrect when LPA Lee and care staff Kaydia and Cleopatra counted the residents’ medications. Resident’s medications did not match up with the Start date of when the resident started the medication; therefore, it is unclear if resident received their medications. It was also learned that on the LIC 622 CSMDR medication start date is not filled out correctly. Care staff Kaydia had to call the pharmacy to determine the start date for 3 out 4 resident medications. Per administrator, Mark Labella and both care giver Kaydia and Cleopatra stated that administrator, Mark Labella come to the facility once a week to audit medication; however on 10/05/2023 3 out of 4 residents medication had discrepancy. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099. An exit interview was conducted with Kaydia and Cleopatra and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility. Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free of pests. Allegation: Staff not keeping facility free from odor. It was alleged that staff are not keeping the facility free from odor. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents who have no concern with the facility having an odor. 10 of 10 residents also shared that they have not witnessed any odor in the facility and in their room. LPA Lee conducted a complaint follow-up investigation on 09/12/2023, 09/26/2023, 10/05/2023 and 10/2023 and LPA Lee did not observe the facility to be odorous. Furthermore, during these complaint follow-up visit, LPA Lee observed facility staff sweeping, mopping, doing the dishes and laundry. Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free from odor. An exit interview was conducted with both care staff Kaydia and Cleopatra and this report was given to the facility at the end of the visit.