Complaint Investigation Report

Multiple relevant parties reported to the Department varying accounts of medication mismanagement by facility staff. LPA reviewed an internal document indicating that, on 1/1/2023 during a medication audit, it was found that a medication that was supposed to be given to a resident was not in the medication bin. Through more investigation, it was determined that the medication was reviewed and approved by Memory Care Director (MCD), Belinda Prunty, and listed to be “injected” even though the facility does not have injectable medication that they can administer. It was documented that MCD did not check to see if medication was at the facility and records indicated that medication had been marked as “given” by other med-techs.

During a visit conducted on 5/17/2023, LPAs Michael Hood and Angela Hood conducted a medication count for residents R1 and R2, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPAs observed three (3) medications for R2 that were off count in relation to what was documented. All three medications that were off count were over the amount documented. Facility was able to account for 1 day (4/29/2023) in which R2 was out of the facility, but no other refusals were documented that could account for the amount over what was documented. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation.

Multiple relevant parties reported to the Department that facility staff are not assisting residents with bathing. Interview with resident (R3) indicated that they went 5 to 6 weeks without a shower when they were requesting to have a shower. Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week.