complaint·July 30, 2024

continued from 9099 LPA's medication audit of Medication Administration Records (MAR) for eight (8) randomly selected residents indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies.The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews with five (5) staff revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with ten (10) residents in care revealed they did not express any concerns as it related to receiving their medications. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation, “staff mismanaged resident’s medication” is deemed Unsubstantiated at this time. It was reported that “Staff member yells at resident(s) in care”, as it was alleged that the Executive Director yells at residents and ignores their concerns. Interviews conducted with ten (10) residents revealed that nine (9) out of (10) residents interviewed have never observed the Executive Director to speak inappropriately to any resident or ignore their concerns . One (1) resident stated they have heard the Executive Director raise their voice attempting to redirect a resident who was yelling at the Executive Director. LPA’s interview with eight (8) staff revealed that each staff have not witnessed any staff yell at any resident or ignore any concerns of the residents in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation “Staff member yells at resident(s) in care” is deemed Unsubstantiated at this time. It was reported that "Staff do not ensure that facility is clean" as it was alleged that the facility is roach infested, unkept and there is a bad smell throughout the hallways. Interviews conducted with ten (10) residents revealed that all (10) have not observed roaches in the facility , have never observed a foul order in the facility and have observed dedicated housekeeping staff cleaning throughout the day. Continued from 9099-C Interviews with eight (8) staff revealed that all staff have not observed roaches in the facility. Two (2) out of the (8) staff interviewed stated that the facility may be malodors when staff are cleaning sheets of residents who had a heavy bladder or bowel movement, but staff are quick to remove the foul linen so the smell does not linger for too long. In addition, records review revealed, that the pest control conducts general treatment of rooms and commons areas at least every other week. Since May 2024, there have been ten (10) visits conducted by pest control company with one (1) visit in May the pest control company discovered a minor activity of roaches under a sink in the kitchen. Since May there has not been another visit where roach activity was found. Records review of daily room cleaning assignment logs revealed that trash containers are emptied and floors are mopped every day. Then twice a week the furniture is dusted, mirrors are cleaned, windows are cleaned, towels are replaced, and bathrooms are cleaned. During physical plant, LPA did not observe any foul odors or roaches. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation "Staff do not ensure that facility is clean" is deemed Unsubstantiated at this time. It was reported that “Staff do not ensure that fire exits are free of obstruction” as it was alleged that fire exits are always blocked by wheelchairs and walkers. Interviews conducted with ten (10) residents revealed that all (10) residents have never observed fire exists blocked by wheelchairs, walkers or any other objects. Interview eight (8) staff revealed that six (6) out of the (8) staff interviewed have never observed any exits obstructed by any object. Two (2) out of the (8) staff interviewed that when medications are passed out residents line up outside of the medication room and there are multiple residents with wheelchairs and walkers, but there is always a clear path to walk to the nearest exits in the event of an emergency. During physical plants, LPA did not observe any exits obstructed by wheelchairs, walkers or other objects. . Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation " Staff do not ensure that fire exits are free of obstruction " is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.