complaint·September 24, 2024

At 10:00 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were conducted from 10:00 am to 12:30 pm. LPA requested and obtained copies of updated resident roster, updated LIC 500, Administrator Certificate and Liability Insurance. LPA requested copies of Physician Reports for all residents, and any other information pertaining to the investigation. LPA Casillas conducted interviews with Administrator, two (2) staff and six (6) residents out of six (6) that were present at the facility at the time of the visit. Allegation #1 Facility retains resident(s) with prohibited health condition(s). It is alleged that facility retains resident(s) with prohibited health condition(s). Regarding this allegation, it is reported that on an undisclosed date, a medical emergency call was made, and emergency personnel were dispatched to the facility where it was observed that a person with bedside suctioning equipment, a dislodged nasogastric tube, and a gastrostomy tube, was residing and receiving care in the facility. Interview with the Administrator revealed that the person in question was in fact an adult relative of the Administrator’s that resided in the home, who was fingerprint cleared, and not a Resident. The Administrator states that the relative has since passed and is no longer at the facility. The Administrator stated that the facility is their primary home, however there is a separate area where the Residents have their own living quarters. LPA interviewed staff that confirmed that Administrator lives in the facility with their relative and that living quarters are kept separate for both staff and residents. Furthermore, it was confirmed by staff that the person in question was not a facility Resident, but a relative that lived in the home. LPA interviewed Residents present in the facility and they also confirm that the persons living in the staff room are staff and relatives of the Administrator. LPA reviewed documentation and the person in question is/was listed as a cleared adult allowed to be in the home. LPA also reviewed all Resident files and none of the Residents currently residing in the facility have a prohibited health condition, therefore based on observations, record review, and interviews, this allegation is deemed Unsubstantiated. Continued on LIC9099-C Allegation #2 Over-occupancy in Resident bedroom(s). It is alleged that there is over-occupancy in Resident bedroom(s). Regarding this allegation, it is reported that there are three (3) beds being used in the primary room. Interview with the Administrator revealed that the room in question is the staff room, and no Residents have access to that room. Administrator stated that the three beds are for personal use and are not all used at the same time. Interviews with staff confirmed that the room with three (3) beds is the staff room and that the beds are for personal use. Interview with Residents revealed that Residents do not have access to the staff room therefore they do not know what is contained in that room. During LPA tour it was noted that staff room is labeled “Staff Room Only”, it was locked and inaccessible to Residents. LPA also observed that all Resident rooms are adequately being used for the number of beds/residents allowed per the fire clearance. Based on observations, file reviews and interviews this allegation is deemed Unsubstantiated. Allegation #3 Facility not kept in a safe condition. It is alleged that the facility is not kept in a safe condition. Regarding this allegation, it is reported that there was an excessive amount of storage in the primary bedroom and that there was an excessive amount of extension cords that were running up the wall causing a fire hazard. Interview with the Administrator revealed that the room in question is the staff bedroom where all the belongings are for personal staff use. Administrator states that the extension cords that were in use at the time of the complaint were used for medical equipment that was for the relative that was being cared for by the Administrator, and that all the equipment has since been removed. Interviews with staff confirmed that the staff bedroom is used for staff personal use only and that Residents do not have access to that room as it always remains inaccessible. During LPA’s tour of the facility, it was observed that all Resident rooms as well as areas throughout the facility were clean and clear of clutter. LPA was granted access to the staff room where it was observed that the room was clean and free of clutter as well as free of excessive extension cords. LPA did not observe any extension cords being used in Resident rooms nor was there an excessive amount of storage throughout the facility to cause a hazard. Therefore, based on observations and interviews this allegation is deemed Unsubstantiated. No citations issued. Exit interview conducted. Copy of report given to Administrator.