Complaint·April 19, 2022

On 4/15/2022 at 12:00 pm, LPA interviewed Staff #1 (S1) who stated that they were aware of an incident where Staff #2 (S2) had given a PRN to Resident #1 (R1), and R1 did not request it. On 4/19/22 at 2:05 pm, LPA reviewed a document title “Employee Warning Notice” dated 9/09/2020. In the Notice, there were two infractions on medication errors. S2 was noted to “have signed for a medication that was never given” and “Med Error for Carbidopa Levodopa from bubble pack.” Both infractions were in August 2020, and S1 was demoted from Med-Tech to Personal Care Assistant. Based on evidence obtained, the allegation “Facility staff did not give medication as prescribed,” is deemed Substantiated at this time. S1 was found to have performed medication errors which could have caused injury to residents in care. Exit interview conducted, deficiency cited, and report and appeal rights emailed to the administrator and VP of Operations. On 4/15/2022 from 11:48 am to 2:35 pm, LPA interviewed five staff. All five staff stated that when a resident has dementia-like behaviors, staff inform their supervisor, and the resident is tested for a UTI. If the resident does not have a UTI, the resident is assessed by their physician. If physician diagnoses a resident with dementia, management meets with the resident’s family and discusses steps for moving the resident to a facility with a higher level of care. Based on evidence obtained, the allegation “Facility retains residents who require more care and supervision than is provided by the facility” is deemed Unsubstantiated at this time. Documentation shows the facility is not retaining residents with dementia and staff interviews corroborate the process for ensuring residents with onset dementia are assessed and given the care needed. Exit interview conducted and report emailed to the administrator and VP of Operations.