Complaint Investigation Report

The administrator stated they had forgotten to destroy the medication. LPA requested destruction records for previous residents and found that that R2 had a documented destruction record for medications. During the time of the visit, the administrator destroyed R1’s medication and documented this. Due to medication being found during the time of today’s visit that the administrator failed to destroy, the allegation is substantiated.

Regarding “Staff left resident in soiled clothing for extended amount of time.”, it was alleged that overnight staff at the facility were not changing resident and as a result were left soiled overnight. LPA interviewed night staff at the time of the visit who stated that residents were changed every 2 hours, including overnight. They stated R3 was the only incontinent resident at this time of the interview, June 23, 2023. LPA reviewed the incontinence accountability log for R3 and found that on several occasions the resident was not documented as changed after 5pm, with next time changed as 5am. Therefore the allegation is substantiated.

A finding of substantiated means the preponderance of the evidence standard has been met. Substantiated finding was cited under Title 22 Division 6 Chapter 8. Plan of correction was made with the administrator.

An exit interview was conducted with administrator, Ana Stark where this report, LIC9099-D and appeal rights were reviewed and provided to them.