complaint·December 22, 2022

Between 12:38 pm and 1:53 pm, LPA spoke with the administrator. Administrator states that on rare occasions staff have brought pills they found to her and she destroys them. She says recently staff found two pills in the living room and placed these in her office. She says she immediately destroyed the pills. She states she was unable to identify the pills as the markings were dissolved. Administrator states that they have one resident who occasionally hides pills in “pockets” of their mouth, and she has instructed staff to look closer in resident’s mouth to ensure this doesn’t happen. Between 12:55 pm and 2:00 pm, LPA interviewed staff. Staff say when they dispense medications to residents, they watch residents to make sure they take all their medications and ask residents to open their mouths so they can see that they’ve taken them. Staff showed LPA where medications are stored. LPA observed resident medications in a cabinet in the locked office in the garage. LPA observed staff opening the office with a code on the keypad. Staff say the office door is always locked. Staff state that they only retrieve medications from the office at the time residents need to take them. LPA reviewed medication administrator records (MARS) for all five residents. Administrator and staff interviews reveal that topical medications are being recorded when given and all other medications are being recorded when prepared. LPA advised the administrator to follow the instructions on the MARS which state, “Put initials in appropriate box when medication is given”, not when prepared. Based on evidence obtained, the allegation “Facility staff did not ensure medications were locked,” is Unsubstantiated at this time. There is no evidence indicating medications are being stored improperly or mismanaged. Exit interview conducted and report emailed to the administrator.