complaint·September 10, 2024

Facility does not have adequate staffing to meet resident's needs: It was alleged that the facility is chronically understaffed. To investigate the above allegation, LPAs conducted records review and inspected the facility’s staff schedule. The schedule indicates that there are three shifts. During the day shift there are two (2) staff scheduled. During the night shift, there is only one staff available. Additionally, interviews with the Administrator and two staff revealed that they always have MedTech as a backup staff to cover for any shift, or during an emergency. Interview with a resident and two (2) out of six (6) family members did not express any concerns with the facility being understaffed. Furthermore, during today’s visit LPAs observed enough staff available to provide care and supervision to residents in care. Based on the record review, interviews and LPAs observation, this allegation is deemed Unsubstantiated at this time. Staff does not follow up on resident's doctor's appointments: Regarding the allegation that Staff do not follow up on resident's doctor's appointments, it was alleged that Staff do not consistently follow up on after care, nor medications directives from doctor/hospital visits. LPAs’ Huma Rahimi, and Raymond Comer, conducted a facility records review and observed that Resident#1 (R1)’s appointments were both scheduled and noted as completed with the assistance facility Staff. LPAs’ interview with the Administrator, two (2) Staff caregivers, and Staff Licensed Vocational Nurse (LVN) revealed that the staff drove residents regularly to complete resident doctor's appointments. Additionally, Staff interviews revealed that in the event of any scheduling conflicts, Staff contacted both physicians and resident’s families that appointment rescheduling was necessary. Based on LPAs’ records review, interview with staff and residents, this allegation is deemed Unsubstantiated at this time. Staff is mismanaging resident's medications: It was alleged that the facility has not followed on after care and/or medications for residents. To investigate the above allegation, LPAs reviewed medication log for Resident #1 (R1) and did not observe any discrepancy or missed medication. Additionally, LPAs reviewed the monthly transportation log of R1’s doctor’s appointments and did not observe any missed appointments. Furthermore, interviews with the Administrator, Licensed Vocational Nurse, and two (2) staff revealed that all scheduled doctor’s appointments are completed with the assistance of the staff or family members. LPAs were informed that the facility also provide third party transportation in case of unavailability of the facility’s transportation. Interviews with a resident and two (2) out of six (6) family members revealed that they never missed any medication or follow up doctor’s appointments. Based on the record review, interviews and LPAs observation, this allegation is deemed Unsubstantiated at this time. Continue on LIC 9099C Facility handrail is in disrepair: With regards to the allegation of facility handrails being in disrepair, it is alleged that handrails along ramp leading from kitchen to the outside courtyard area are broken and have been in disrepair for several months. LPAs’ Huma Rahimi, and Raymond Comer, conducted a physical tour of the facility and found handrails secure and in good repair. A review of the facility’s maintenance repair ticketing system shows that on July 10, 2023, a ticket was generated with high priority to repair handguard rails; documentation indicates the repair was completed the same day. Interviews conducted with residents and their conservators evidence a consensus opinion that the facility is safe, and that facility plant issues are resolved in a timely basis. Based on LPA observation, records review and interviews with residents, LPAs has determined that this allegation is deemed to be Unsubstantiated at this time. Exit interview conducted and report issued.