It is alleged that staff engaged in vaping while on the premises. Regarding this allegation it is reported that Staff #1 (S1) was vaping what smelled like marijuana on the premises while in the presence of clients. LPA interviewed Administrator and one (1) staff members present who stated that there is no smoking allowed on the premises, this includes vaping. Administrator states that while clients are allowed to vape and/or smoke, it is to be done outside in the designated areas, staff members are to vape or smoke off premises on their breaks. LPA was able to speak to Staff #1 (S1) via telephone and they also denied this allegation, stating that they do vape tobacco, but it is always on a break and off premises. Interviews with Administrator and staff denied this allegation stating that they do not partake in smoking or vaping on facility premises. LPA interviewed two (2) out of four (4) clients. Client #1 (C1) revealed that S1 could have been smoking a wax pen but is not too sure and cannot say with certainty what was being smoked, furthermore C1 states that S1 was not in the facility when they saw S1 smoking. Client #2 (C2) denied this allegation. Based on interviews and observations, this allegation is deemed Unsubstantiated.

Allegation #2 Staff did not administer medication to resident as prescribed.

It is alleged that staff did not administer mediation to a resident as prescribed. Regarding this allegation it is reported that Client #1 (C1) asked Staff #1 (S1) for their medication to be administered but was refused their medication by S1, when C1 repeated the request to S1, S1 provided C1 with the medication. LPA interviewed Administrator and it was discovered that C1 has recently refused medication, however other prescribed medication has not been missed or denied. LPA interviewed Staff #2 (S2) who also stated that C1 has refused their medication on occasions with other staff but not with them, therefore no medications have been missed. LPA was able to interview Staff #1 via telephone and it was stated that medication is not refused to residents, and that all medications are provided when prescribed or needed if medication is an as needed medication. During LPA’s interview with Administrator, it was stated that C1 will also refuse medication or will attempt to hide medication in their pockets, so they take extra care in making sure that all medication is accounted for. LPA interviewed C1 and C1 denied the allegation stating that staff administer medication when it is due. Client #2 (C2) denied this allegation stating that medication is given to them and nothing has been missed. Furthermore, LPA reviewed medication logs and compared medication instructions noting that there were no discrepancies. Therefore, based on file reviews, observations and interviews, this allegation is deemed Unsubstantiated.

Continued on LIC9099-C

It is alleged that staff falsify residents' records. Regarding this allegation it was reported that staff are falsifying residents’ medication records due to staff signing out medication to a client that was not present at the facility at the time that the medication was signed out at. LPA interviewed Administrator and it was revealed that when clients go home, medications are prepackaged for them and handed off to a responsible party to administer the medication while the client is not at the facility. When the medication is signed for with staff initials, it indicates that the medication was administered and by whom. When the staff prepackage the medication to take home, the medication log reflects the initial “F” for “Family” indicating that the medication was prepackaged and sent home with the client, therefore staff do not sign with their own initials as the medication was not administered to the client in their presence. This is common practice as the entire bubble wrap where medication is stored cannot leave the facility. Staff do not give the entire monthly dose to anyone at any given time, therefore weekend mediation is placed in a different container with instructions on how to administer. LPA interviewed Client #1 (C1) and client confirmed this practice, furthermore they confirmed that they do not have any missed doses of medication, and that what was witnessed was just S1 writing in medication log, but it was not clear what was written. LPA interviewed Client #2 (C2) and they deny this allegation stating that they have not witnessed staff falsify any documentation. LPA reviewed medication logs and it was discovered that all medication that is prepackaged, is logged as such and it is notated when it is given to a responsible party to administer to client when clients are not present at the facility, this action calls for a signature or a mark indicating “F”. Further review of the medication log revealed the initial "H" for "Hospital" stay, hence a missed dose as the client was not at the facility and the initial "R" for "Refused" when clients refuse to take medication. Based on file reviews, interviews and observations this allegation is deemed Unsubstantiated.

No citations issued. Exit interview conducted. A copy of this report was given to Administrator.