complaint·May 26, 2021

Another resident indicated that they didn’t have access to their PRN (as needed medication) in December 2020 because staff could not find it. Staff interviewed reported that prior to the TM2 arriving to the facility, the medications were not being handled properly. Medications were reportedly found on the floor or in wrong medication bottles. TM2 indicated that the prior Temporary Manager (TM1) admitted that some of the residents were not receiving their medications daily because there was insufficient staff. Based on interviews conducted and records reviewed, the allegation is substantiated. Allegation: Staff are not properly feeding the residents while in care. 1 resident indicated that when TM1 was operating the facility the food was not good and many times staff were bringing food from outside. 3 staff interviewed confirmed the food was not of good quality when TM1 was operating the facility and staff confirmed that many times food was being brought from outside because facility did not have a cook. TM2 reported that she had to hire a cook when she began to operate the facility because TM1 did not have a full-time cook. Based on interviews conducted, the allegation is substantiated. Allegation: Facility has inadequate record keeping. Staff interviewed confirmed that the records were disorganized when TM1 was operating the facility. LPA reviewed MARs and confirmed the medication records were not being completed as required. Based on interviews conducted and records reviewed, the allegation is substantiated. Allegation: Staff failed to meet residents’ incontinence needs while in care. TM2 reported that the first day TM2 took over operation she had a nurse evaluate all the incontinent residents. There were many residents with redness possibly due to not being changed often. Other staff indicated that when TM1 was operating the facility there was insufficient staff to change all the residents and staff confirmed that they would find the residents really wet and their beds would be wet. Based on interviews conducted, the allegation is substantiated. Allegation: Staff did not provide laundry services to residents. 1 of the resident’s interviewed indicated that there were no staff to do laundry when TM1 was operating the facility. 1 staff indicated that residents were complaining about their laundry not being done. Another staff indicated there was no one assigned to laundry when TM1 was operating the facility. The laundry didn’t get done until TM2 arrived. Based on the information obtained, the allegation is substantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights were provided. Allegation: Staff are not meeting residents’ health related services. It’s alleged that staff were not changing Resident #2’s (R2) colostomy bag properly. Staff interviewed indicated they didn’t have information about that issue. R2 has since passed away and therefore, could not be interviewed. Other residents interviewed did not have any information regarding R2. TM2 indicated that when she arrived to the facility, R2 was non-compliant with staff when they attempted to assist R2 with the colostomy bag, but eventually started allowing staff to change the bag. Based on the information obtained, the allegation is unsubstantiated. Allegation: Staff are not meeting the minimum qualifications required by licensing. Residents interviewed did not corroborate the allegation. Residents indicated the facility started running smoothly once TM2 arrived to the facility. Staff interviewed also did not corroborate the allegation. LPA obtained proof of staff training from 12/20/20 - 1/15/21. The following topics were covered: COVID-19 protocols, medication policy and procedures, and mental health and well-being awareness. Based on the information obtained, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided.