complaint·April 2, 2024

2 out 7 staff members state that once reviewed by management they send the incident report within 10 days of occurrence via fax and notify the LPA via email if the fax is unsuccessful. LPA reviewed facility documentation to review incident reports for the past 3 months and was provided copies of all and any incident reports dating back to September 2023. It was observed by this LPA that the facility is properly reporting to all parties involved with supporting documents sent out as well. Based on the information gathered it is unclear of the staff do not ensure reporting requirements are being following. Facility staff mismanages resident medication. It was alleged that facility staff mismanages resident medication. During the course of this investigation, LPA conducted interviews, toured the facility and reviewed facility documentation. Based on interviews conducted, 7 out 7 staff members deny that they have mismanaged any resident medication. 7 out 7 staff members state that they are confident in ensuring that each resident is provided with the right and correct amount of medication. On 12/12/2023 and 03/12/2024 LPA Pascua observed 4 separate medication passes in which observed that the Medication Technicians were providing the residents with the correction medication. LPA observe medication stored at the facility to match physicians orders and medication dispensing logs. LPA Pascua reviewed medications on 12/12/2023 and 03/12/2024 which reflected that the facility was providing medication as ordered by the physician. Based on the information gathered, it is unclear if the facility staff mismanaged resident medication. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.