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32 | It was alleged that staff did not deliver Resident #1 (R1)’s medication. Record review and interviews confirmed that R1 is not on a medication management program and that R1 manages their own medications. Staff do not administer or centrally store R1’s medications. R1’s physician’s report signed and dated 02/13/2025 documents that R1 is “able to administer own prescription/PRN medications” and is “able to store own medications.” R1’s assessment signed and dated 03/07/2025 documents that R1 “self-manages medications and self-manages orders/refills.” Interviews revealed that staff attempted to deliver R1’s medication refill to their door past 5PM which is R1’s do not disturb hours. Staff made multiple attempts and were able to deliver the medication at 10PM. ED held a meeting with R1 and R1’s responsible party to discuss medication delivery and came to the consensus that medications will be held at the front desk until R1 can pick up or the medications can be delivered to R1’s door directly by R1’s pharmacy. Based on interviews and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not administer medication as prescribed” is deemed UNSUBSTANTIATED at this time.
It was further alleged that the facility does not have a backup generator and that R1 did not have access to power during a power outage even though they require oxygen 24/7. Staff and resident interviews confirmed that there is a generator and that residents had access to power when there was an outage. Staff and residents also confirmed that frequent checks were made to residents on oxygen during the outage to ensure that oxygen machines and tanks were functional. At 02:21PM, LPA observed the facility’s backup generator outside of the facility with a valid permit to operate. The generator appeared functional and had a fuel level of 90%. LPA reviewed the facility’s emergency disaster plan which documents that there is a permanently installed generator on the southwest side of the community, and it can be used for all three (3) elevators, common area lighting, main kitchen freezer, and main kitchen cooler. Based on interviews, record review, and observation, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation “Facility does not have a back up generator” is deemed UNSUBSTANTIATED at this time.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
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