complaint·May 16, 2022

An interview with R1 states R1 is receiving hygiene care attempts by staff. Based on interviews and record reviews, it is determined that there is not a preponderance of evidence to conclude R1’s hygiene needs are not met or not being attended to by staff, therefore, this allegation is UNSUBSTANTIATED. Allegation #2: Resident’s toileting needs are not met. LPA interviewed Administrator, S1, S2, and S3. LPA also reviewed care log sheets for R1, service plan for R1, physician’s report for R1, and interviewed R1. Based on record reviews, and interviews it was determined that the service plan addressed needs for R1 which includes full toileting assistance. It was further revealed through care log documentation that R1 consistently exercised resident right of refusing toileting assistance offered by staff. A review of service plan revealed interventions are in place to address R1’s refusal of care. An interview with R1 states R1 is receiving toileting assistance attempts by staff. Based on interviews and record reviews, it is determined that there is not a preponderance of evidence to conclude R1’s toileting needs are not met or not being attended to by staff, therefore, this allegation is UNSUBSTANTIATED. Allegation #3; Staff prevent resident from having visitors. Allegation stated facility has isolated R1 from having in person visits and phone calls. LPA interviewed Administrator, S1, S2, S3, and R1. LPA also reviewed facility visitation log. Based on interviews, it was revealed that R1 is allowed visitors and phone calls. It was also revealed through interviews that R1 occasionally declines phone calls. Visitation log observed by LPA indicates R1 received in-person visits during March 2022 and April 2022. LPA also tested facilities phone communication system in memory care to ensure functionality. Phone system functioned appropriately during LPA's visit. Based on interviews and record reviews, there is not a preponderance of evidence to conclude that facility is isolating R1 from having visitors or phone calls, and this allegation is UNSUBSTANTIATED. An exit interview was conducted with Jennell Revera and a copy of this report was left with Jennell. Appeal Rights provided. During medication audit for R1 it was revealed that a Quetiapine medication order for 25 milligrams (mg) is to be given 1 tab twice per day as needed for agitation and behavior. A medication count of the Quetiapine order as noted above for R1 was conducted during audit by S4 with Administrator and LPA present. Medication count revealed that 60 tablets were filled on 7/17/21 with 38 tablets remaining in bottle as of 5/16/22. Medication log sheets reviewed indicate R1 did not receive Quetiapine since its fill date of 7/17/21. Based on interview and record review, it was determined that there are no records existing which include a physician’s order or pharmacy change relating to the Quetiapine medication order noted above. Based on interviews, it was revealed that staff is instructed to assist R1 with medications as ordered and notify R1’s physician of any changes in condition. Based on the records reviewed and interviews conducted, it is determined that facility did not adequately manage the Quetiapine medication order for R1 in that a total of 22 pills are missing from the Quetiapine medication bottle with label reading and matching the physician’s order of 1 tablet twice per day as needed for agitation and behavior. Additionally, it is determined that this medication is not properly documented, in that accompanying documentation for this medication did not include when medication may have been given, the dosage taken, and R1s response to this medication. Additionally, R1’s medication log sheets indicate this medication was not given since it’s fill date, which is inconsistent with medication count conducted. Based on interviews conducted, records reviewed, and medication audit conducted, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citations are issued today under Title 22, Division 6, Chapter 8. An exit interview was conducted with Jennell Revera and a copy of this report was given to Jennell. Appeal rights provided.