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13 | On 6/01/2021 at 10:50am Licensing Program Analyst (LPA) Tirzah Hubbard and Ashley Boothe conducted an onsite inspection to deliver the investigation findings of the following allegations: "Staff falsafied facility records, "Based on Interviews and records review Staff 1 documented medication incorrectly on MARS. LPA's met with Adminsitrator Bethany and stated the purpose of the visit. Administrator contacted the licensee Jerald Plasma who was present over the phone for this delivery of findings.
During the Investigation LPA TIrzah Hubbard reviewed Resident One's (R1)’s Medication Adminstration Records (MAR). MARS verified R1 recieved the correct medication. Staff 1 documented the medication in MARS incorrectly and notified Administrator of the mistake. The incorrect documentatin on MARS was deleted. Changes were made to R1 MAR to show medication adminsitered as physicians order. The facility uses an electronic MARS system and oncall staff have access to permanent staff logins. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.No deficiencies were cited on todays visit. An exit interview was held and a signature on this report acknowledges a copy was provided.
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