complaint·April 26, 2022

Staff are not providing an accurate dosage of medication to a resident . During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) was not interviewed, as she is no longer residing at the facility. Documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal. Staff persons stated that they were not aware of an inaccurate dosage of medication that was given to a resident (Resident 1). It was reported that the resident was on hospice and not only were the med technicians ensuring that the medication was given correctly, it was reviewed by the hospice nurse also. The resident has since moved, and her medications could not be reviewed; however, during the process of this investigation, a site visit was conducted, and three residents were randomly selected for medication review. Medications were present and were in order, as required. It could not be proven that Staff are not providing an accurate dosage of medication to a resident. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . No deficiencies cited. Unqualified staff are administering medication to residents. During the interview process, the assistant administrator and four staff persons were interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Relias Computer Training Records. continued Required Training for staff hired after 01/01/16 includes: Cultural Competency, Personal Care Services; Physical Limitations and Needs of the Elderly; Residents’ Rights; Dementia Care; Building and Fire Safety and Appropriate Response to Emergencies; Antipsychotic and Psychotropic Medications; Policies and Procedures Regarding Medications; and Postural Supports, Restricted Health Conditions and Hospice Care. It was reported and verified that staff persons are trained through Relias Online Training and then provided training by shadowing a more experienced staff person for the required 16-hour initial training. In addition, transcripts for three employees were reviewed to indicate that they had the appropriate training, in administering medications to residents. It could not be proven that the Unqualified staff are administering medication to residents. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . No deficiencies cited. A resident’s diapers were not changed in a timely manner which resulted in a rash . During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal. Hospice notes indicated that Resident 1 was able to make her basic needs known to the staff persons, which was supported by staff statements during the interview process. Peri care was recommended by the hospice nurse to include changing incontinent care products and to ensure that the resident did not suffer from a skin breakdown. A review of the hospice notes indicated that the resident did not have a rash, wound, or ulcer/bed sores. In addition, staff persons follow a “Tier Level System” with resident names that indicate which residents are incontinent and need assistance with being clean and dry with their incontinent products. continued It could not be proven that A resident’s diapers were not changed in a timely manner, which resulted in a rash. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . No deficiencies cited. Staff are not responding to residents’ call buttons in a timely manner. During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Inservice Training on Call Bell Policy and Procedures. Staff persons signed off that they were present for the training. Staff persons were interviewed, and they reported that they try to respond to the call buttons within a five-minute period. The training that was provided to the staff stated that if the staff person on call for the resident could not attend the resident within the five-minutes, then it is their responsibility to radio another staff person to assist. Overall, it was reported that staff respond to the residents in a timely manner. It could not be proven that Staff are not responding to residents’ call buttons in a timely manner. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . No deficiencies cited. continued A resident’s belongings were stolen. During the interview process, the assistant administrator, and four staff persons were interviewed. In addition, the Ombudsman advised that she met with the resident to discuss the resident’s Property and Valuables List. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Personal Property and Valuables List for the resident. It was reported and documents reviewed, that the assistant administrator along with the Ombudsman reviewed the resident’s Personal Property and Valuables List (two lists) with the resident. The assistant administrator and the Ombudsman could not determine or substantiate any of the resident’s items missing. It could not be proven that A resident’s belongings were stolen. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . No deficiencies cited. continued Staff not providing food to a resident in a timely manner. Staff are not providing adequate food service to a resident. Staff are not providing residents with food of good quality. During the interview process, the assistant administrator, four staff persons, two cooks and three residents were interviewed. The resident (Resident 1) has moved and was not interviewed. The facility’s food service policy and menu were reviewed. It was reported that meals are served at 8:00 a.m., 12:00 p.m., and 5:00 p.m. and that snacks are provided twice a day. It was stated that residents either eat in the dining room or in their rooms. An unannounced walk through of the kitchen was conducted and the lunch menu consisted of Salisbury steak, green beans, potatoes with gravy, rice crispy treats and/or sugar free Jell-O. The cook advised that she serves 50 residents in the dining area and 11-15 residents are given tray service in their rooms. The cook stated that the care providers and the med technicians assist when serving the residents, as needed. Dinner was also in preparation and was observed to be lemon chicken, vegetables and rolls. The food being served appeared to be of good nutrition and was being served hot. A menu was observed in the kitchen and the cook was following the daily menu. During the interview process, overall, it was reported that the residents do receive their food in a timely manner, that there was adequate food and that the food was of good quality. It could not be proven that Staff are not providing food to a resident in a timely manner, Staff are not providing adequate food service to a resident and Staff are not providing residents with food of good quality. Although the allegations may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated . During the investigation of this Complaint #25-AS-20211011102847, a deficiency was noted and shall be cited on a separate Facility Evaluation Report (LIC 809).