Complaint Investigation Report

Allegation: Staff administered resident medication with a foreign substance in it. It is alleged that medication staff administered resident (R1) medications in a cup that contained a white powder substance. The resident does not have physician orders for crushed medications. When the resident tasted the white powder substance it had a strong sour taste. In addition, it is alleged that the white powder substance was observed in other areas of the facility i.e. lobby, elevator, and pool table. According to staff interviews, resident (R1) has psychiatric issues that include paranoia. A total of 10 residents were interviewed. Three (3) out of 10 residents stated they have observed wrong medications in the medication cups that may be foreign substances. All staff denied the allegation. Staff were shown pictures of the alleged foreign substance noticed on the resident's medication cup. All staff stated that the small amount of white residual powder depicted on the picture appears to be traces of Benedryl "Banophen" capsule pill that is administered to resident (R1). According to staff, sometimes when med-tech staff pop the medication from the medication bubble pack the capsule releases a little powder unto the cup. Based on photo evidence observation and interviews conducted there is insufficient evidence to corroborate the allegation.

Allegation: Staff did not prevent resident from inhaling hazardous chemicals in elevator. It is alleged that the elevator is contaminated with a chemical smell that is causing breathing issues for residents. A white powder observed outside the elevator door that looked like a chemical. The smell of concern inside the elevator is marijuana smoke. According to information obtained residents smoke marijuana inside the facility premises, especially in the evening and nighttime hours and when they use the elevator the smell gets trapped. In addition, it is alleged that the smell was also noticeable when a staff (name unrecognized) was on shift, and the smell "went away" when the alleged unknown staff stopped working for several months. Interviews revealed that the elevator sometimes has a strong body odor smell because there are residents that have poor hygiene. A total of 10 residents were interviewed. Three (3) out of 10 residents stated they have smelled hazardous fumes in the elevators, which include marijuana smoke. Staff confirmed there are residents that smoke marijuana outside the facility premises and sometimes when they enter the facility the smell lingers in the areas they pass through i.e. elevators. In regards to the white powder observed outside the elevator (photo obtained), it is not a chemical, cleaning agent, or detergent. But rather, it is dry wall powder that fell on the floor after maintenance staff installed hand sanitizer wall stations in hallways, next to elevator, between public restrooms, activity room, and med-room. The dry wall dust was not cleaned immediately. It was cleaned up after all hand sanitizer stations were installed; which was approximately an hour later. A month ago the facility installed air fresheners throughout the facility corridors and in the elevator to mitigate resident body odor smells that offend some residents. No toxic or hazardous odors were smelled during today's visit.

Based on interviews conducted and record review, the findings indicate that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

Exit interview conducted with Assistant Administrator Andrew De Vera. A copy of the report was issued.