complaint·October 24, 2023

9099C -1... LPA, RCC and a Med-Tech staff reviewed medications for (5) residents who occupy (4) rooms mentioned in the complaint. All medications for (R1) were on hand except for the medication, Lactulose 10/15 g/ml that ran out yesterday. RCC stated that this medication is ordered by hospice and (R1) refuses medications daily and hospice is aware. RCC stated that this medication has a pending discontinuance order. All medications were on hand for (R2. Medications were reviewed for (R3). All medications listed on the most recent physician's orders (Sept 2023) were found to be on hand and are being administered per the orders There were (3) prior medications that (R3) was prescribed from when she was in the hospital. RCC stated these (3) medications were not taken since (R3) returned from the hospital and have been discontinued. RCC is trying to get approval for (R3) to begin Home Heath. Medications for (R4) and (R5) were reviewed and found to be on hand and are being administered currently. LPA observed all documentation on the Medication Administration Record (MAR) and Centrally Stored Medication Record to be current and legible. LPA, Administrator, RCC and (1) Med-Tech staff conducted a narcotic count for (3) randomly selected residents. The count matched the number written on the Narcotic Documentation page for all (3) residents (R6, R7 and R8). Based on review of medications and medication counts, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have inadequate records keeping for the residents medications. The complaint alleges the central stored binder is a mess. LPA reviewed the Centrally Stored Medication Binders and observed it to be organized with tab dividers. The pages (LIC622) were completed by hand and filed with the more recently logged medications first. LPA observed a few loose, torn pages in each binder, but the binder overall was very neat and organized. LPA discussed ways with the Administrator to possibly eliminate staff having to write the same information repeatedly for the same medications on the LIC622. cont on 9099C-2... 9099C-2... LPA also reviewed the Centrally Stored Narcotic Binder which was recently created by the RCC. The binder was also organized with tab dividers by each resident room. LPA also reviewed the Narcotic counts and observed (1) entry for each shift change and (2) signatures to have been written on most days, after each narcotic count. The Administrator stated that sometimes when a staff works a double shift, she or the RCC acts as the second staff who counted the narcotics. The facility was cited recently for not documenting completely for PRN medication specifically. Ongoing training is being done regarding proper documentation for medications. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. Allegation: Staff have not repaired the pull cord system in the facility. Allegation states the pull cord system is not working with no specific details included. LPA, Administrator and RCC tested multiple (4) bathroom pull cords on 10/24/23. LPA observed each pull cord to light up when pressed and heard the RCC announce on the walky the Administrator was carrying that assistance was requested in the specific room. LPA also observed a staff member to arrive at the identified room promptly after the pull cord was pulled. LPA spoke to the Maintenance Director who confirmed that he and the Administrator check weekly to ensure the pull cords are working properly. The Administrator confirmed that the Maintenance Director will begin in room #101 and pull both the bathroom and resident pull cords and she will be watching the monitors in the RCC's office. The Administrator will then communicate with the Maintenance Director, using a separate walky to not interfere with staff's lin e during their testing process. The Director stated maybe 1-2 batteries are found to occasionally need replacement, but not on a regular basis. Based on documentation review, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without reasonable basis. There are no deficiencies issued on this report. Exit interview. Copy of report provided to the Administrator.