complaint·March 17, 2023

On 07/01/2021 LPA Basili conducted facility staff interviews between 9:45am - 2:30pm. 03/10/2023, LPA Urena interviewed the complainant from 12:46 p.m. to 1:50 p.m., and on 03/17/2023, LPA Urena interviewed facility staff from 2:15 p.m. to 2:30 pm. Staff is using resident’s medication. On the allegation that ‘Staff is using resident’s medication’; it is the complainant’s concern that a staff member at the facility would go into the medication room and ask the med techs for medication, pharmacy samples and even medication that belonged to the residents. To investigate the allegation, LPA Urena interviewed the complainant. The interview revealed that the complainant had witnessed a staff member go into the med room to request pharmacy samples of medication, and sometimes would ask for medications for specific ailments. The complainant further stated that they had instructed the med techs, that no one, other than the med tech, was allowed to be in the med room, and to never give medications to anyone other than to the resident that the medication belonged to. LPA Basili interviewed three staff members, and asked if they had ever witnessed any staff, besides the med tech enter the medication room and access the medication of the residents?. Staff #1 (S1) stated, ‘They believe medication is distributed to residents when they eat’. S1 has never noticed anyone go into the medication room that did not have access. S1 also has never witnessed staff request medication from other staff . Staff #2(S2) stated, ‘They believe that only they, and the other med tech have access to the med room. S2 also stated that as long as they have worked there, they have never witnessed any staff in the medication room, and that they have not witnessed staff requesting other staff for any type of medication from the med room. Staff #3(S3) stated, ‘For as long as they have worked there, they have not witnessed any staff enter the medication room and attempt to access the medication cart’. Although the allegation that ‘Staff is using resident’s medication’ may have happened, based on the information obtained through interviews, there is not sufficient evidence to support this allegation. Therefore, this allegation is deemed Unsubstantiated at this time. Continues on LIC9099C... Staff does not meet the minimum qualifications required. On the allegation that ‘Staff does not meet the minimum qualifications required’; the concern of the complainant was that the administrator did not have collage units to perform the job of an administrator. To investigate the allegation LPA Urena interviewed the complainant. The interview revealed that the complainant was informed by another facility staff member that the administrator on duty during the 2020 year, did not have academic units. According to the complainant, the administrator was transferred to another facility shortly after they arrived at the facility. LPA Urena asked the complainant if they ever saw an Administrator Certificate for this administrator; the complainant stated that they were not aware of a certificate, nor they asked other staff if indeed this administrator had an active Administrator Certificate. Additionally, the complainant stated that they never saw the administrator’s personnel file to be able to vet the certification or education of the administrator. On 03/17/2023, LPA Urena conducted a website search for the administrator’s name in the CCLD Resources/Administrator Certification link, and was able to confirm that the administrator has an active administrator’s certificate at this time. Although the allegation that ‘Staff does not meet the minimum qualifications required’ may have happened, based on the information obtained through the interview, and web search, there is not sufficient evidence to support this allegation. Therefore, this allegation is deemed Unsubstantiated at this time. Staff failed to prevent a resident from wandering. On the allegation that ‘Staff failed to prevent a resident from wandering’; it is the concern of the complainant that the facility does not have enough staff to supervise residents, which lead to a resident with dementia wondering off the facility. To investigate this allegation, LPA Urena interviewed the complainant. The interview revealed that the complainant did not know the name of the resident, the incident happened in late 2019, before the complainant arrived at the facility. The complainant found out about the resident’s elopement through another facility staff. Although the allegation that ‘Staff failed to prevent a resident from wandering’ may have happened, based on the information obtained through the interview, this allegation is deemed Unsubstantiated at this time. Continues on LIC 9099C... Staff denied a resident access to the facility while in care. On the allegation that ‘Staff denied a resident access to the facility while in care’; it is the concern of the complainant that the facility staff denied access to a resident that was under the care of the facility. To investigate the allegation, LPA Urena interviewed the complainant. The interview revealed that the resident #1(R1) had tested positive for COVID 19 in December 2020. R1 was told by staff that they needed to be quarantined in their room, however R1 refused, and made it to the reception area where the complainant and another staff were working. Complainant stated that they were horrified to see R1 in the reception area, because R1 refused to stay in their room. The staff then called the paramedics, and R1 refused to go to the hospital. The paramedics told facility staff that they could not make R1 go against their will. Since R1 refused to quarantine in their room or go to the hospital, the complainant stated that the administrator instructed the staff to lock R1 out of the facility. According to the complainant, R1 spent a night in their car, then when R1 was able to get in the facility again, R1 retrieved their belongings, and said that they were going to the hospital. Based on the information obtained though the interview, the facility staff attempted to provide care to R1, and followed COVID-19 positive protocols to contain the spread of the virus; however, R1 refused the care, placing R1, other residents, and the staff in danger of contracting the COVID-19 virus. Therefore, the allegation that ‘staff denied a resident access to the facility while in care’, is deemed Unsubstantiated at this time. Staff did not address a resident's change in medical condition. On the allegation that ‘Staff did not address a resident's change in medical condition’, it is the concern of the complainant that the administrator did not address R1’s change in condition, when R1 tested positive for COVID-19. To investigate the allegation, LPA Urena interviewed the complainant. According to the complainant, R1 had made statements in the past that if they ever contracted COVID-19, they would disappear, hurt themselves, and no one would know their whereabouts. Once R1 tested positive for COVID-19, the complainant texted the administrator that they may have to do a 5150, due to the mental status of R1, however, the administrator ignored the complainant’s request, and approval for the 5150. The complainant added that R1 became furious when they were not allowed back into the facility (after R1 refused to quarantine, or go the hospital). This is when the complainant requested to do the 5150 for R1, and their request was ignored. LPA was unable to I interview R1. R1 passed away Continues on LIC 9099C... Based on the information obtained through the interview, and complaint report, the facility staff addressed the change of condition when R1 tested positive for COVID-19. Although the mental condition of R1 may have been unclear at the time of the positive results; per the complainant’s statements, R1 was angry because they were not allowed to enter the facility due to R1’s refusal to quarantine in their room or go to the hospital, putting everyone at risk of contracting COVID-19. Based on the complainant’s interview and report, R1 remained outside the facility in their car, and after R1 was able to retrieve their belongings from their room, R1 themselves announced to facility staff that they were going to the hospital. Therefore, the allegation that ‘Staff did not address a resident's change in medical condition’, is deemed Unsubstantiated at this time. Staff did not provide a safe environment for a resident while in care. On the allegation that ‘Staff did not provide a safe environment for a resident while in care’; it is the concern of the complainant that resident #2(R2) always came out of their room when the hallway floor was wet, the complainant reported the incidents to the administrator, and the administrator never responded back. To investigate the allegation the LPA interviewed the complainant and staff. The interviews revealed that when staff mops the hallway floors, staff places a ‘Caution' yellow sign to make residents aware of the wet floor. LPA was unable to interview R2. R2 is no longer residing at the facility. Based on the information obtained through interviews, there is not sufficient evidence to support the allegation that Staff did not provide a safe environment for a resident while in care. Therefore, this allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted with Malikah Sillah, facility representative, and a copy of the report was issued.