Complaint·August 29, 2023

It was alleged staff did not ensure an incontinent resident was kept clean. It was reported a source had witnessed R1 to have stool around the groin area after staff had assisted R1 with incontinence care. Interviews with staff, residents and external sources, including R1, revealed staff assisted the residents with incontinence care and there were no concerns with residents being left uncleaned. It was alleged staff did not give a resident medication as directed by the physician. It was reported to the Department a source witnessed staff had not provided R1 a prescribed medication. On one occasion this source witnessed a medication pack indicating R1 was only provided two doses out of a thirty-dose supply. Interview with staff, residents and external sources did not reveal any concerns regarding lack of assistance with medication management. R1 corroborated R1’s medication was provided as indicated. Staff confirmed there was one occasion where R1’s medication had arrived, but the facility had not received a physician’s order. The order was requested, and medication assistance was resumed for the medication. On a separate occasion, an outside agency nurse requested a probiotic be administered until the cycle was completed, although, the order indicated only while the resident was on antibiotics. An interview with the agency’s supervisor corroborated the facility requested the correct order to be provided. Order was provided and medication was resumed. This supervisor met with facility management and R1, who revealed no concerns regarding lack of medication management, nor assistance. Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated. An exit interview was conducted with Boller, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.