Complaint Investigation Report

September and October 2024 Medication Administration Record (MAR) for R2 did not reveal medication errors. Interview with R2 indicated staff has not made medication errors. Record reviewed revealed five residents (R3 – R7) with unusual incident reports that resulted in hospitalization in September – October 2024. On 10/16/24, R3 went to the hospital due to shortness of breath. Interview with Wellness Director indicated R3 takes three medications for diagnosis and an inhaler. October MAR revealed that R3 took the three medications daily and had access to R3’s inhaler from 10/01/14 – 10/15/24. Interview with R3 indicated there hasn’t been any medication errors and hospitalization was not caused by medication errors. R4 and R5 MAR’s did not reveal medication errors. R6 went to the hospital for primary diagnosis and MAR revealed R6 took medication prior to hospitalization. R6 was unavailable for interview. R7 went to the hospital for diagnosis. Interview with Wellness Director indicated that R7’s medication list is reconciled by the Nurse after every hospitalization. Interview with R7 indicated staff have not made medication errors and hospitalization was not caused by medication errors. Five out of seven staff interviews indicated there were no medication errors in September and October 2024. One staff member was unsure. Six out of ten residents indicated there were no medication errors in September and October 2024.

Regarding the allegation “Staff mismanaged residents’ medication," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

Regarding the allegation "Residents are not provided adequate meals," it is being alleged that the facility does not provide fresh food and recycles previous meals from the week to make a different dish. Also, it is being alleged that the facility only provides half portion of the meals and it constantly cause diarrhea. Record review revealed fruit and vegetables are available upon request for morning and afternoon snack, vegetables and occasionally fruit are served for lunch, and vegetables and soup of the day are included at dinner. Three staff interviews clarified that unserved ingredients from lunch are used in the soup at dinner time. One of the three staff members (S5) have a food handler certificate valid from 04/16/24 to 04/16/27. Six staff interviews indicated there has not been an increase of diarrhea at the facility. Week 6 menu revealed Sunday’s lunch included baby back ribs, mac & cheese, baked beans, sliced pears, and assorted beverages. Continue to LIC9099-C.