Complaint·July 27, 2023

(Continued from LIC9099) Outside source interview revealed R1 to have a longstanding history of inconsistent statements regarding care at the facility. Outside sources did not have direct knowledge or observation of medication errors at the facility. No outside sources interviewed had concerns regarding medication administration errors by staff. Records review revealed that R1 had multiple changes to the administration of their medication regarding self/staff administration, timing intervals, discontinuations/reorders from their physician, and POA authority for consent. Records review revealed 8 out of 10 medications prescribed to R1 were ordered to be unsupervised self-administration per physician. No records reviewed revealed medication errors by facility staff. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Meegan Kline, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.