complaint·April 11, 2022

During today’s visit, the LPA conducted a physical plant tour with Administrator Evelina Papazyan at 10:06 a.m., to ensure there are no health and safety hazards. From 9:30 a.m. until 11:28 a.m., the LPA briefly spoke with the administrator; and reviewed and obtained copies of documents pertinent to the investigation. From 11:28 a.m. until 12:44 p.m.; and between 1:33 p.m. until 1:47 p.m., the LPA conducted interviews with facility residents. From 1:10 p.m. until 1:33 p.m.; and between 2:00 p.m. until 2:30 p.m., the LPA conducted interviews with facility staff. Regarding the allegation, ‘Facility leaves residents in soiled clothing for extended period of time,’ the complainant’s concern is that residents go 8-10 hours without being changed, due to the facility having insufficient Personal Protection Equipment (PPE) gear such as gloves. During the investigation, LPA Richardson conducted an interview with the administrator. LPA Walker also conducted interviews with facility residents, and staff. Interview with the administrator revealed that residents were changed 4 or 5 times per shift, in 8 hour shifts. Interviews with facility residents revealed that staff would check on the resident ‘regularly’ wearing PPE gear ‘like mask, shields, and gloves.’ Interviews with residents also revealed that staff would change, and dispose of their gloves in between duties to avoid cross contamination. Interviews with facility staff revealed that during the COVID-19 Pandemic in the year of 2020, the facility continued to perform their duties in providing services to the residents such as assistance with the changing of clothes, brushing teeth, and hair to get the residents ready for the day. Interviews with staff also revealed that staff wore ‘full PPE gear,’ including gloves; and that staff would change, and dispose of their gloves every time they entered/left a resident room. Based on interviews with the administrator, facility residents, and staff, there is insufficient evidence that residents would go 8-10 hours without being changed, due to the facility having insufficient Personal Protection Equipment (PPE) gear such as gloves. Therefore, there is insufficient evidence to support the allegation ‘Facility leaves residents in soiled clothing for extended period of time.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Continue LIC-9099C.. Regarding the allegation, ‘Facility staff are not ensuring that residents are eating and drinking,’ the complainant’s concern is that residents are not receiving appropriate care. The complainant is also concerned that food is dropped off to the resident rooms, but staff do not ensure that residents are eating and drinking. To conduct the investigation, the LPA attempted to contact the complainant to obtain additional information such as specific residents that required assistant with meals. However, after multiple attempts the LPA was unsuccessful. During the investigation, LPA Richardson conducted an interview with the administrator. LPA Walker also conducted interviews with facility residents, and staff. Interview with the administrator revealed that Staff would go inside resident rooms with the exception of residents who requested their food be dropped off outside their door. Interviews with facility residents revealed that staff would deliver their meals into their rooms, and would check their plates once they were done. Interviews with residents also revealed that some residents did go through occasions when they would not eat all their meal, however, ‘staff would call on the intercom, or cell phone to check in and offer something else.’ Interviews with staff revealed that staff would monitor residents were eating by checking the plates when picking up the trash. Interviews with staff also revealed that residents that required assistance with feeding were assisted by staff in proper PPE gear. According to staff, if a resident did not want to eat, the facility would offer other options, including ‘Ensure’ as additional nutrition. Staff also reported to the front desk/ office any resident that would not eat or ate minimal. Based on interviews with the administrator, facility residents, and staff, residents were receiving appropriate care, and the facility was ensuring that residents were provided the require nutrition. Therefore, there is insufficient evidence to support the allegation ‘Facility staff are not ensuring that residents are eating and drinking.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation, ‘Facility staff are not keeping the facility clean,’ the complainant’s concern is that staff are not cleaning or disinfecting contaminated areas. Continue on LIC-9099C.. During the investigation, LPA Richardson conducted an interview with the administrator. LPA Walker conducted a record review, interviews with facility residents, and staff. Interviews revealed that staff cleaned and disinfected high touch surface areas ‘daily,’ ‘every hour to half an hour.’ Record review confirmed, that the facility staff were disinfecting, and cleaning all high touch surface areas on an hourly basis. Based on record review, interviews with the administrator, facility residents, and staff the facility was following CDC guidelines and cleaning or disinfecting contaminated areas. Therefore, there is insufficient evidence to support the allegation ‘Facility staff are not keeping the facility clean.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was emailed.