LPA Lee also reviewed Medication Administration Records (MARs) for seven residents for May 2024 and identified two documentation discrepancies. Resident 4 (R4) was prescribed Ocean Blue Omega-3 2100 mg, one capsule by mouth daily, with a start date of 05/02/2024 and an end date of 10/10/2024. The MAR did not have staff initials from 05/02/2024 through 05/06/2024, and no documentation to explain the omission. Resident 5 (R5) was prescribed Methylphenidate 5 mg tablets, two tablets (10 mg) by mouth three times daily, with a start date of 02/29/2024 and an end date of 08/21/2024. The MAR contained no staff initials for the morning, noon, or evening medication passes on 05/02/2024 and from 05/06/2024 through 05/16/2024. No notes were documented explaining the missing entries.

Based on facility incident reports and the review of resident MARs, the investigation revealed medication administration errors, as a result, the allegation is found to be SUBSTANTIATED, meaning the allegation was found to be valid because the preponderance of evidence standard was met.

The following deficiency was not cited as the same citation was already cited on complaint control number 22-AS-20240919164250. An exit interview was conducted with FDA Turner. A copy of this report was provided to the facility via email, and a certified copy will be mailed to the facility's address of record.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegations are unsubstantiated. An Exit Interview was conducted with (FDA) Turner, and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.

During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff, residents, and a resident's responsible party. LPA Lee interviewed two out of two facility staff members, who both denied the allegations. LPA Lee attempted to interview eight additional staff members; however, those attempts were unsuccessful. LPA Lee interviewed two of three residents in care, both of whom denied the allegations and reported no concerns regarding the allegations. Resident 1 (R1) stated that they were regularly changed and received showers twice weekly and has no concerns with the allegations. LPA Lee attempted to interview twenty-six additional residents; however, those attempts were unsuccessful. LPA Lee also interviewed a resident's responsible party, who denied the allegations, reported no concerns regarding the care and supervision provided by facility staff, and stated they were satisfied with their family member's placement at the facility. The responsible party further indicated they had not witnessed any of the alleged incidents. The investigation also revealed that R2 was receiving hospice services during the time of the complaint; however, hospice records were not available for review. Additionally, LPA Lee was unable to contact facility staff who may have worked during the time the alleged incidents occurred and was unable to interview R2. Additionally, a review of facility records revealed that the facility did not maintain documentation indicating when residents' clothing was changed, when residents were dressed, or when residents' briefs were changed. Therefore, LPA Lee was unable to verify through record review whether R1 did or did not receive these services as alleged. Therefore, LPA Lee was unable to corroborate the allegations.

It was alleged that staff did not follow infection control practices. During the investigation, Licensing Program Analyst (LPA) Pang Lee reviewed facility records and conducted interviews with staff and residents. LPA Lee interviewed two of two facility staff members, both of whom denied the allegation and stated that they do follow infection control practices.

CONTINUED LIC 9099-C