complaint·June 27, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff do not administer resident's medication as prescribed by physician The complainant alleges administrator forgot to give resident their medication. LPA toured facility grounds and reviewed files. LPA noted that facility has three medtechs, one per shift, to hand out resident medications. Per administrator Susie Fuentes, only if the medtechs are out will the administrator give out medications. LPA reviewed Medication administration record and noted that no medications were missed on 10/9/2021 or 10/10/2022 for R1. LPA spoke with residents (R2-R7) regarding the allegations. Six out of six residents interviewed stated they are taking medications and they are given to them daily by staff and at the correct times. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, 4 out 7 stated the residents received medications timely, with the other three stating they did not know. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff do not administer resident's medication as prescribed by physician ” Allegation: Staff do not assist resident with incontinence care. The complainant alleges that residents are not being assisted with their incontinence needs. LPA reviewed facility documents and noted that facility has a list of all residents with incontinence care needs, the list outlines which staff will be changing the residents. LPA interviewed residents regarding allegation and 2 out of 6 residents stated they received assistance with incontinence care, 3 of those interviewed stated they assisted themselves and 1 did not answer. Of the staff interviewed, 5 out of 7 stated the facility staff assist residents with incontinence care with the remaining two staff stating it was not part of their job duties. Based on information gathered, the department did not find sufficient evidence to support allegation “ Staff do not assist resident with incontinence care.” Continued on 9099-C Allegation: Staff do not allow resident to keep personal care item in room The complainant alleges that staff are not allowing residents to keep personal care items in rooms. LPA Cifuentes toured the facility and noted adult incontinence briefs in several of the rooms, reusable bed pads, lotions, and bathing supplies. LPA Cifuentes spoke to Administrator who stated residents can keep personal care items in their rooms, but their were issues with residents taking incontinence supplies from other residents who were not as alert or ambulatory, so some of those supplies were being kept in storage. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed 6 out of 7 stated they were allowed to keep personal care items in their rooms. One of those interviewed did not answer the question. LPA interviewed S1-S6 regarding allegation. Out of those interviewed 7 out of 7 staff stated that residents are allowed to keep personal care items in their rooms, with some staff adding that it depended on the cognitive level of the resident.. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff do not allow resident to keep personal care item in room Allegation: *Staff and residents are not provided adequate masks. The complainant alleges that residents are not being provided masks by facility. LPA toured facility and noted that receptionist gave resident a mask when they requested one. LPA spoke to facility administrator, who stated facility staff has sufficient PPE for their needs and residents are provided masks when they request them. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed, 6 out of 7 stated masks were provided upon request, with on resident not answering question. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, 7 out of 7 stated that facility proved both staff and residents with masks when needed, several staff adding that there is a supply of masks in front office for that purpose. Based on information gathered, the department did not find sufficient evidence to support allegation " * Staff and residents are not provided adequate masks.” Continued on 9099-C Allegation: *Facility is not following universal precautions. The complainant alleges that staff are not provide with gloves or trash bags to dispose of waste. LAP interviewed administrator Fuentes, who states that gloves supplies are checked by maintenance supervisor and extra quantities are supplied at the end of their shift as needed for the upcoming shifts. Administrator also stated that staff are provided with black trash bags for incontinence waste, which they then throw away outside. LPA interviewed residents R2-R7 regarding allegation and of those interviewed 1 out of 7 stated that staff take incontinence waste with them when they leave their room. The other 6 interviewed did not know what happened to incontinence waste or declined to answer. LPA spoke to staff S1 – S6 regarding the allegations, and 7 out of 7 staff stated they used gloves to change residents, with 2 of the 7 stating it was not part of their job duties. Of the staff interviewed, 5 out of 7 staff stated incontinence waste is put in a bag and disposed of outside of resident rooms, with 2 of the 7 stating it was not part of their job duties. Based on information gathered, the department did not find sufficient evidence to support allegation “ *Facility is not following universal precautions. Allegation: Facility limits residents use of toilet paper The complainant alleges that the facility only gives residents one roll of toilet paper a week. Per administrator Susan Fuentes, residents receive toilet paper daily. LPA spoke with residents (R2-R7) regarding the allegations. Of those interviewed 3 out of 6 stated they had toilet paper in their rooms while the other 3 did not know. LPA interviewed staff S1-S6 regarding allegation. 6 out of 6 staff stated that residents have toilet paper in their rooms, and that there was extra available if any of the residents requested the item. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility limits residents use of toilet paper” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Staff do not administer resident's medication as prescribed by physician,” “Staff do not assist resident with incontinence care,” “Staff do not allow resident to keep personal care item in room.” “Staff and residents are not provided adequate masks,” “Facility is not following universal precautions,” “Facility limits residents use of toilet paper.” 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 . An exit interview was conducted with Susana Fuentes and a hard copy was provided.