complaint·July 17, 2023

Allegation: “Staff do not administer resident's medications in a timely manner:” It was alleged that Resident #1 (R1)’s medications were administered up to 3 hours late at times. At the time of the allegation, R1 had moved out of the facility, so LPA was unable to review R1’s medications. However, LPA obtained R1’s Medication Administration Record (MAR) for the month of August 2021. MAR reviewed indicated R1’s medications were initialed as administered daily as prescribed until the date of R1’s move out, with the exception of R1’s Certrizine 5mg, which was marked as not administered, as the medication was unavailable. Staff interviewed indicated that medications scheduled at a certain time can be administered up to an hour prior to the scheduled time to an hour after the scheduled time. For example, if a medication is scheduled at 8:00AM, a medication technician could administer that medication anywhere from 07:00AM to 09:00AM and still be within an appropriate timeframe for medication assistance. Staff interviews revealed that if a medication was administered outside the appropriate timeframe, this would be reflected on the MAR as an exception, documented, and reported accordingly. Resident interviews revealed that medications are provided to the residents on time as prescribed. As R1 had moved out of the facility prior to the complaint investigation, LPA was unable to interview R1 or observe R1’s medications more thoroughly. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not administer resident’s medications in a timely manner” is deemed UNSUBSTANTIATED at this time. Allegation: “Food service is inadequate:” The complaint alleges that food was not provided to R1 for two (2) days. During an initial complaint visit, LPA obtained copies of the facility menu and foods offered. During an unrelated visit, LPA observed dinner service as well as food trays delivered to residents. LPA also observed lunch time in Memory Care during an annual visit. Each time LPA observed meals to be served to all residents in the dining room and in Memory Care. LPA observed the food in Memory Care is brought on a cart into the Memory Care unit and the care staff serve the residents the pre-plated foods. Residents have been seated at the table and the assigned care staff assist those who require feeding assistance. Staff interviews revealed that there are a few residents who prefer to stay in their rooms during mealtimes, particularly during the pandemic. Care staff hand deliver plates to those residents who choose to remain in their rooms. Staff interviewed could not recall a time when a Memory Care resident did not receive a meal or complained of not receiving a meal. Based on interview and Report Continued on LIC 9099-C observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “food service is inadequate” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff did not safeguard resident's personal items:” The complaint alleges that R1’s personal items went missing from R1’s room and were unable to be located. LPA reviewed R1’s LIC 621 (personal property and valuables) dated 07/29/2021 and corresponding photographs provided by R1’s family member. LPA observed items circled on the photographs and marked as missing. Items included 2 packs of flash cards, a flowered scarf, and one item that appears to be a dark colored blanket. Interview revealed that R1 did indicate items were missing often and every time R1 could not locate an item, staff assisted them in looking for the item. Staff interviewed indicated to their knowledge, items were usually located and returned to R1. R1 was unable to be interviewed for the complaint investigation, as they no longer resided at the facility at the time of the initial complaint investigation. Other residents interviewed indicated they maintain their personal belongings in their own rooms and have not had items that were lost, only temporarily misplaced. Staff interviewed indicated R1’s family moved all R1’s personal belongings out of the facility. When the move out occurred, items were not marked on the LIC 621 as “personal property/valuables removed” at that time, so it is unclear which items, if any, were not safeguarded. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “staff did not safeguard resident’s personal items” is deemed UNSUBSTANTIATED at this time. Allegation: “Resident is not accorded privacy:” The complaint alleges that staff have “ruffled through [R1]’s drawers” and staff have been overheard asking R1 who they are on the phone with. Record review revealed that R1 resided in the Memory Care unit and while R1 was independent with dressing themselves, R1 did require reminders for most ADLs. Additionally, R1 was noted to be “alert and oriented with bouts of confusion and forgetfulness.” Staff interviews revealed that R1 reported to staff regularly that something was missing from their room. Staff would offer to help R1 locate any missing item and at R1’s request, would help look for and attempt to locate missing items. As a part of that assistance, staff did assist the resident in looking around their room for the missing item, which did include looking in R1’s dresser drawers. Interviews also revealed that staff frequently check on all Report Continued on LIC 9099-C residents, including R1, by stopping in their rooms to do a visual and/or verbal check to ensure the resident’s health and safety. R1 was on the phone regularly when they would come in R1’s room to complete the health and safety check. Staff did inquire if R1 was on the phone when they enter R1’s room and when R1 indicated they were on the phone, staff would leave the room and allow R1 privacy. Interview with residents revealed that residents feel they are accorded privacy at the facility. Therefore, based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation that “resident is not accorded privacy” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.