Complaint Investigation Report

Based on the lack of a cohesive policy regarding washing resident’s personal drinking cups that aligns with general food service sanitation practices and LPA’s observation of an unsanitary cup the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Staff are mishandling the residents medications

During the course of the investigation LPA Jensen inspected the medication room. LPA Jensen observed 2 plastic cups containing multiple pills. Each cup had the number 12 on it and a resident’s first name only. LPA Jensen interviewed the Medication Technician on duty and inquired why the medication was there. The Medication Technician stated that it appears the Medication Technician attempted to administer the medication at noon the prior day but was unsuccessful for some unknown reason. LPA Jensen reviewed the Medication Administration Record (MAR) for the residents in question and determined that the medication was signed off on as having been administered. LPA Jensen’s findings were verified by a physical count of the medications. In addition, the facility submitted an incident report to advise that all of the February 2024 MAR had gone missing without explanation. It should be noted that the records went missing at approximately the same time that 2 employees were facing disciplinary action and were subsequently separated from employment with the organization. Based on the inaccurate MARs, missing MARs and medication not administered without explanation the allegation of staff mishandled resident’s medications is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Staff do not provide a comfortable temperature for the residents

LPA Jensen interviewed a resident that stated the room is very cold in the mornings and that there is no thermostat in this particular unit. The resident further stated that this issue has been brought to the attention of staff and for this reason the resident has extra blankets. LPA Jensen interviewed the Maintenance Director who stated there was previously an issue with the heat but was addressed immediately and repaired within a week. The Maintenance Director also stated that there is currently a problem with the air conditioner and the repair is pending management approval. LPA Jensen reviewed maintenance records and invoices and determine that on 3/22/24 an invoice from a mechanical vendor states “While performing your routine maintenance, Lakeside technician found the following: Swamp cooler needs a new motor which has been shorted to the ground.” Based on the resident interview and maintenance invoice reviewed the allegation that staff do not provide a comfortable temperature for residents is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.