Complaint Investigation Report

Interviews with staff reveal food is ordered and delivered weekly. Based on the interviews this allegation is UNSUBSTANTIATED.

Staff does not ensure residents medical equipment is properly maintained

LPAs observed and interviewed staff and witnesses. Observations revealed 1 resident was using medical equipment and was functioning correctly. Interview with witnesses and staff reveal medical equipment for residents R5 and R2 has all the parts of their medical equipment to function correctly. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff dispensed medications not prescribed to residents

Interviews with staff reveal medication is audited by the administrator to ensure medication is given accurately before staff provide it to residents. LPA observation reveals medication was labeled and separated for each resident name in their own basket. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff did not discard discontinued medications

Interviews with S5 and S6 revealed that when a medication is discontinued it is relocate to another locked cabinet and notated that it is discontinued upon doctors’ orders and notify the other staff. S5 stated they crush the medications when there is an order that it is discontinued. Based on the interviews and observation this allegation is UNSUBSTANTIATED.

Staff did not prevent residents from developing pressure injuries

LPAs conducted interviews with staff and relevant parties. Based on interviews and record reviews it was revealed that R2 and R5 have in the past or presently experienced a pressure injury. Interviews and records review revealed they were between stage 1-2. LPAs observed Hospice nurse providing care and treatment and records indicated Home Health and hospice have been providing treatment. Interview revealed that R5 has a red mark that has opened in lower coccyx area and R2 has a pressure injury on R2’s foot. Staff have been monitoring it injury and staff have been treating it by elevating the R2 foot. Based on the interviews and observation this allegation is UNSUBSTANTIATED.