complaint·October 23, 2024

LPA Jensen also conducted an interview with the Executive Director. The Executive Director explained that the facility did not have a physician's order for one of resident 1 (R1's) medications upon move in. In addition there was confusion regarding who would administer the medication. R1's family wanted R1 to self administer medication however R1 was unable to do so effectively upon initial assessment by the facility nurse. The records reviewed support the statements made by the Executive Director. The medication administration records show that facility staff attempted to obtain the physician's order for the medication in question within 1 day of R1's arrival. The emails reviewed also show that R1's family member had brought medication in after move in that was not sent with R1 upon arrival. While there does appear to be a misunderstanding regarding a medication that R1 should be receiving there is insufficient evidence to show any negligence on behalf of facility staff. Based on the records reviewed and the interview conducted the allegation of " Staff did not ensure medications were dispensed as prescribed" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it. Allegation 2: Staff did not ensure residents incontinence care needs were being met LPA Jensen conducted a site tour and observed approximately 30 residents engaged in various activities. All residents observed appeared to be well groomed. LPA Jensen also interviewed 8 residents, 3 staff members, a resident family member and a hospice worker from an outside agency. All residents interviewed stated that their care needs are met in a timely manner. All others interviewed stated residents received frequent and timely incontinence care. One staff member said there have been occasions where residents had been left in soiled briefs but that this occurred only about 2 x a month and the situation was improving. Based on the interviews conducted and LPA Jensen's own observations the allegation of " Staff did not ensure residents incontinence care needs were being met" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report was provided. LPA Jensen also reviewed an email exchange between the resident care director and a responsible party for a resident. In the email the resident care director advised that the facility's goal is to have staff respond to pages within ten minutes. Based on the call log showing response times to be in excess of the facility's goal or expectations more than 68% of the time the allegation of " Staff do not ensure call signal system requests are answered in a timely manner" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited on the LIC 9099D. An exit interview was conducted and a copy of this report was provided.