complaint·January 16, 2025

The information obtained during the investigation did not include evidence sufficient to corroborate the allegation related to proper medication training. One (1) staff file for Staff #1 (S1) observed was missing 20 hours annual training and was cited on a Case Management – Deficiencies visit during today’s visit. However, S1 does not handle or prepare medications. Interviews with staff, Licensee, and residents confirmed that S1 does not administer or prepare medications. LPA observed the remaining two (2) staff files to be complete and have no missing documents or trainings. Records confirmed that all staff handling medications receive proper medication training annually. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation that Licensee did not provide proper medication training is deemed Unsubstantiated at this time. The complaint also alleges that the facility is mismanaging residents' medications, including improper preparation and documentation of medications administered. LPA reviewed medications for two (2) residents, which were observed to be administered as ordered and documented on both the Centrally Stored Medication and Destruction Record (CSMDR) and the Medication Administration Record (MAR) in accordance with regulation. LPA observed no discrepancies during the medication review. The MAR form was not pre-filled out or signed and is updated daily as medications are administered. LPA observed the MAR forms for two (2) residents with last documented medication administered yesterday 01/15/2025 at 05:00PM. Residents interviewed confirmed their medications are administered by the staff and are given as prescribed. Staff indicated that morning medications are prepared the night before and that during the day they prepare the rest of the day's medications, as time permits. Staff indicated that at no time are medications prepared more than one (1) day in advance. During medication review, LPA observed medications for today's 05:00PM, tomorrow’s 08:00AM, and tomorrow’s 05:00PM medication passes were pre-prepared. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation " Staff are mismanaging residents' medication " is deemed Unsubstantiated at this time. Licensee was unable to stay for the remainder of the visit and designated staff Patrick Sangalang to sign the report. No citations issued. Exit interview conducted. A copy of today's report was provided.