Complaint Investigation Report

Staff are mismanaging resident medication-Complainant alleges that facilty has not properly disposed of narcotics and expired medication. A co-complainant was added for this allegation 11/5/2024 and the Department was unable to reach this individual for additional information. Expired medication can be found in box in health and wellness office and stuffed in drawers. During the course of the investigation LPA made observations in the facility on 7/30/2024, 8/13/2024, 8/15/2024, 8/21/2024 and 9/10/2024 and did not observe expired medication or narcotics pending destruction. LPA reviewed and obtained medication destruction logs which appear to be complete and indicated two signatures. LPA conducted interviews with health and wellness director who showed good understanding of facility policy and regulation pertaining to medication storage and destruction of medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Staff do not have adequate training- Complainant alleges that facility is not in compliance with training requirements, referring to new hire/onboarding and shadowing requirements. LPA obtained a sample of (4) new hire training records and logs. Based on review of training records and interviews conducted facility appears to be in compliance with regulation pertaining to staff training. Annual inspection was conducted on 8/21/2024 and a citation was issued for annual dementia training, but this training requirement was not part of the complaint’s allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Facility telephone is not maintained in working order- Complainant alleges non-payment of invoices has resulted in phone service disruption for a full week. Complainant did not indicate what week was in reference and LPA is unable to contact for additional information. The Department conducted an inspection pertaining to the same allegation in complaint 21-AS-20240521215956 and delivered substantiated findings on 6/4/2024. During the course of this current complaint investigation LPA conducted (6) phone calls to the facility between the dates on 7/23/2-024 and 8/7/2024 that included between the hours on 9am to 4:45pm and all calls were answered by facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099C...