complaint·December 26, 2023

(Continued from LIC9099) Staff interview revealed that Med Techs receive the required number of training hours through a combination of pharmacy training, seminars, and hands-on shadowing. No staff interviewed were aware of untrained staff administering medications. Review of facility records did not corroborate the allegation, revealing pharmacy certifications for Med Tech staff. Resident interviews did not corroborate the allegation; residents did not express concern regarding medication administration, stating their medications were given on time and correctly. Outside sources did not respond for interview. Regarding the allegation, "Staff pre-poured medications", it was alleged that Med Techs were instructed to prepare medications in advance, to be administered at a later time and by other staff members. Staff interview revealed that staff prepare medication immediately before administering them. Residents interviewed did not have knowledge regarding the preparation of medications. No records were found to corroborate that the preparation for medication exceeded the guidelines in order to be considered a "pre-pour". Outside sources did not respond for interview. Regarding the allegation, "Staff did not assist with medication as prescribed", it was alleged that staff refused to administer a pro re nata (PRN) medication upon request, and forged medication counts after misplacing medication. Staff interviews did not corroborate the allegation, as no staff advised witnessing or being informed of a Med Tech not providing a PRN when requested. Staff interviews with records corroboration further revealed that the medication in question was not misplaced, but had been turned in to management and disposed of, per requirement. The resident in question (R2) denied the allegation, stating that staff were helpful and provided their medications on time and upon request when needed. Outside sources did not respond for interview. Regarding the allegation, "Lack of supervision resulted in resident AWOL", it was alleged that a resident was found multiple times wandering away from the facility. Staff interview revealed that the facility does not have a memory care unit and staff are not allowed to prevent residents from entering or leaving the facility of their own will. Staff interview further revealed that the resident in question (R3) experienced an acute change in condition and the Licensee updated the resident's care plan; Licensee also maintained contact with their physician and responsible party. R3 was transferred to a different facility that provided a higher level of care. R3 was unable to be interviewed. (Continued on LIC9099-C) (Continued from LIC9099-C) Records review confirmed that the facility does not have a memory care unit and is not approved for delayed egress doors to keep residents from exiting the building. Records review further revealed that the resident was able to leave the facility unassisted, and the Licensee updated the resident's care plan when the change in condition was observed. Outside sources did not respond for interview. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that residents were not assisted with incontinence care per their needs and were declined help upon request. Staff interviews did not corroborate the allegation; staff members interviewed denied observing or being informed of a staff member refusing to change a resident when needed. Residents interviewed did not receive incontinence services, therefore were not able to provide information regarding incontinence care. The resident in question (R4) was not able to be interviewed due to no longer living at the facility. Records review revealed that R4 began experiencing confusion that resulted in them requesting to be changed multiple times per hour and when no incontinence had occurred. Records review further revealed that R4 was assisted when requests for incontinence help were made. Outside sources did not respond for interview. Regarding the allegation, "Staff did not meet resident(s) basic needs", it was alleged that staff were instructed not to assist Independent Living residents, and the main building was not open for service according to the listed hours, resulting in basic needs not being met. Staff interview revealed that caregivers and Med Techs were mostly concentrated in buildings 5 and 17, the Assisted Living buildings, but also helped the Independent Living residents when needed. Resident interviews did not corroborate the allegation, informing that Independent Living residents were able to call for, and receive, assistance when needed. No records reviewed gave supporting evidence of Independent Living residents not receiving help from staff. Outside sources did not respond for interview. Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff member(s) yelled at a resident(s), pushed a resident, and threw a towel at a resident. (Continued on LIC9099-C) (Continued from LIC9099-C) Staff interviews were mixed, informing that one of the staff members of concern exhibited impatience with residents when they were overwhelmed, but no staff witnessed or corroborated the specific situations named. Resident interviews did not corroborate the allegation, as residents stated staff treat them well. Two residents named in the allegation were unable to be interviewed. Records review revealed that the facility reported the accusation of staff pushing a resident, but the internal investigation was inconclusive. Outside sources did not respond for interview. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Monica Maldonado, Resident Services Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.