Complaint·April 13, 2023

The investigation revealed the following: Allegation #1 : Facility staff failed to feed resident. It is alleged Resident R1 was not fed by facility . On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 reported staff would assist R1 with 3 meals daily. A1 relays that R1 was able to eat in the dining room. If R1 could not make the trip to the dining room due to health, staff would deliver meals to R1. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S2 relays that S2 worked 5 days per week with R1. S2 relays that R1 was capable of walking to the dinning room every day for meals with support from staff. S2 relays that facility staff provide R1 with 3 meals per day and noted that hospice staff would also ensure R1 ate meals. On 11/15/2022 LPA Calderon reviewed physician report for R1. Report relays that R1 had a special diet due to health conditions and able to eat meals independently. Staff S3-S7 reported staff were aware of R1’s dietary considerations. On 04/13/2023 LPA Calderon interviewed R2-R10 regarding complaint. R2-R10 relay that the facility serve 3 meals per day and provide meal plans for those with special diets. R2-R10 relay that staff deliver food to residents who are unable to eat meals in the facility dining room. Allegation #2 : Facility not supervising resident while in care. It is alleged that facility staffing is insufficient and R1 was left unsupervised while in care. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that facility supported R1 needs. A1 relays that the facility maintains sufficient staffing to provide the residents with needed supervision. Staff S2 relays that R1’s medical and care needs were supported by facility staff. Staff S3-S7 relay that R1 had health issues and there was a sufficient number of staff to support R1’s service plan. Staff S3 relayed that there are 3 supervisors working on the floor and 2 staff for each resident during the day. S5 relayed that there is sufficient staff to serve residents in care. On 11/15/2022 LPA Calderon reviewed R1 physician report, needs and service plan, preplacement plan, and hospice care plan. LPA found R1 did have serious health conditions. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 did not express concerns with staffing or needs not being met. R2-R10 relayed that there are many new staff, but that staff do care of resident’s needs. Allegation #3: Facility staff failed to clean residents’ linens. The alleged facility staff failed to clean residents’ linens. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that R1 had health issues and had incontinence issues. A1 relays that staff assisted R1 with hygiene 2 to 3 times per day or when needed. Staff changed R1’s bed linens daily or and as needed. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S5 and S7 relayed that R1 was assisted with hygiene needs 2 to 3 times per day and bedding was changed daily. On 11/15/2022 LPA Calderon reviewed physician report, pre-placement, and hospice records for R1. On 04/13/2023 LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 report staff clean their rooms and change bedding one time per week or as needed. Allegation #4: Faculty staff locked resident in room. It is alleged that facility staff locked R1 in R1’s room . On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that resident would wander due to health issues. A1 states that residents do leave their rooms and wander the hallways. A1 relays that the unit R1 resides in has security to prevent resident from leaving the unit unattended. A1 relays that there are no situations that support any staff locking a resident in their room. A1 relays that resident doors can be secured, but residents are able to leave their rooms freely and staff are able to enter rooms. Staff S2-S7 reported that R1 required assistance transferring from R1’s bed to R1’s wheelchair. Resident R1 was not able to leave R1’s room without assistance from staff. Staff S2-S7 reported residents are not locked inside their rooms. On 11/15/2022, LPA Calderon reviewed hospice records R1’s that indicate R1 is non-ambulatory and requires assistance to transfer. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 reported their room doors are not locked by staff. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility staff failed to feed resident” “Facility not supervising resident while in care” “Facility staff failed to clean resident linens” “Facility staff lock resident in room” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (A1).