Complaint Investigation Report

It is being alleged that facility staff are administering a medication that has been discontinued. On 08/01/24 at 10:35 am LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported that the discontinued medication has not been administered. Per A1 when any medication is discontinued, that medication is taken out of medication cycle. A1 continued to report that when a medication is discontinued a medication destruction takes place and the medication is dissolve as Bonita pharmacy provides facility with a dissolution pack. Between 10:35am- 11:45 am LPA interviewed S1-S4 regarding the allegation above, 1 of 4 staff interviewed reported medications are administrators per Doctors orders and any discontinued medications are labeled and destructed per pharmacy's procedures. 3 of 4 staff interviewed reported being unaware of medication procedures. On 08/01/24 between 9:45 am-10:30 am LPA interviewed C1-C5 regarding the allegation above, 1 of 5 clients interviewed reported concerns that discontinued medications were administered which resulted in a hospitalization. 4 of 5 clients interviewed denied the allegation above and reported having no concerns regarding medications. On 08/01/24 at 12pm LPA interviewed W1 regarding the allegation above, per W1 W1 reviewed hospital discharge summary for July 2024 and there was no order placed by the Doctor for medication in question upon hospital discharge. On 08/01/24 LPA conducted a medication review for May-July 024 and did not observe the medication in question listed on the MAR nor was the physical medication observed.

Allegation: Staff did not ensure the safety of food served to residents.

It is being alleged that facility staff is serving expired food. On 08/01/24 at 10:35 am LPA interviewed A1 regarding the allegation above, A1 denied the allegation above and reported that all food at the facility is dated with expirations dates when it arrives from Costco. Between 10:35am- 11:45 am LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported all food is labeled with expiration date. On 08/01/24 between 9:45 am-10:30 am LPA interviewed C1-C5 regarding the allegation above, 1 of 5 clients interviewed reported being serve a cold meal when the meal should of been warm. 4 of 5 clients interviewed denied the allegation above and reported having no concerns regarding the meals being served at the facility. On 08/01/24 LPA conducted a tour of the facility kitchen and pantry and observed all proteins, can goods, cereals, frozen foods and drinks to be labeled with expiration dates, LPA did not observe any expired food upon tour.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Administrator, and a copy of this report was provided.