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 R2 and R3, 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 do not provide assistance with incontinence care and/or bathing. Interview with resident (R1) indicated that they do not receive assistance with incontinence care and they went 5 to 6 weeks without a shower when they were requesting to have a shower. R1 stated they were refused both due to being required to use a shower chair. Interview with ED indicated that the facility required R1 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident. ED stated that R1 personally made the order for the shower chair and shower chair was not provided by the facility. ED stated that it took 30 days to obtain the first shower chair, in which resident refused to use due to being uncomfortable, and another 30 days to obtain a second shower chair that the resident was able to use. ED stated that R1 was originally admitted with the use of a hoyer lift, but R1 refused to use hoyer lift after admission due to being uncomfortable for resident.