Complaint Investigation Report

Interviews with Staff and Assistant Administrator confirmed that the insulin was never obtained and Glucose testing was not conducted. R1's file was not on site for review. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff does not ensure an appropriately skilled professional administers Glucose Testing and insulin to resident" and "Due to staff negligence, resident missed medications resulting in high blood sugar" has been deemed Substantiated at this time.

It was reported that "Staff is not competent to meet the needs of residents" as it was alleged that staff are unable to communicate effectively with residents and outside agencies. LPA's interview with three (3) out of five (5) residents in care revealed they could communicate their basic needs to Staff #1 (S1), however they could communicate more effectively with use of a translation app. (1) resident declined to be interviewed and another resident was in the hospital. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff is not competent to meet the needs of residents" has been deemed Substantiated at this time.

It was reported that "Staff did not do a proper assessment of resident" as it was alleged that Licensee was unaware who conducted pre-appraisal assessment of R1. LPA's records review of resident records revealed two (2) out of five (5) residents in care did not have a pre-appraisal assessment completed in their file. Interview with Assistant Administrator revealed that an assessment was completed , but staff onsite could not locate R1's records for review. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not do a proper assessment of resident " has been deemed Substantiated at this time.

During the complaint visit ,It was observed that "Staff did not properly safeguard the resident's medications" ,during physical plant and interviews with residents, LPA observed multiple prescribed medication stored and easily accessible in the rooms of Resident #2 (R2) and Resident #3 (R3). Interviews with R2 and R3 revealed they prefer to store it with them. Residents were advised of Title 22 regulations regarding the storage of medications. Based on information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not properly safeguard the residents medications " has been deemed Substantiated at this time.