complaint·April 21, 2021

At the time of the allegation, it was disclosed that on 5/6/2020, R1 was pushed by Resident #2 (R2), which resulted in R1 falling and bruising their right arm. This incident took place in front of staff, yet staff were unable to intervene before R2 pushed R1. The facility self-reported this incident on 5/14/2021. Interviews revealed that R1 is able to ambulate on their own but requires standby assistance because R1 has an unsteady gait. In addition, interviews revealed that R1 attempts to ambulate without staff assistance, yet staff claim they are near R1 at all times to prevent falls. R1’s pre-placement appraisal, dated 2/20/2020, notes that R1 refuses to use their walker. Similar information is reflected in R1’s Needs and Services Plan, dated 2/22/2020, in which it is documented that R1 doesn’t like to get help when necessary, doesn’t want to use walker . Based on the information obtained, there is insufficient evidence to support the claim that due to lack of supervision, R1 fell and sustained a bruise. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff mishandling residents medication It was alleged that staff administered incorrect medication to a resident (name unknown). During today’s visit, the LPA conducted a medication audit at 10:02am. The LPA was unable to find evidence that there were any recent medication errors or that medication was incorrectly given to another resident. The LPA audited the facility Special Incident Reports (SIRs) and did not find evidence that the facility self-reported a medication error. Staff denied claims that any medication errors had taken place. Based on the information obtained, there is insufficient evidence to support the claim that staff mishandled medication. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Licensee does not provide staff training It was alleged that the staff did not receive training on how to work with residents diagnosed with dementia and alleged that staff were not trained to administer medications. During today’s visit, the LPA audited two out of four staff files (S2, S2) at 9:55am. The LPA observed the files to be complete, with all required documents. The LPA observed that the two staff were hired within the last year, and the LPA observed that the staff received the initial forty hours of training as required per regulation. In addition, the LPA observed the correct number of dementia hours required per regulation. Interviews with staff confirmed that they have received training within the past 12 months. The LPA also observed that residents received medication training within the past 12 months. Based on the information obtained, there is insufficient evidence to support the claim that the licensee does not provide staff training. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility has converted the garage to living quarters without a permit/clearance It was alleged that staff were sleeping in the garage. The LPA audited the facility file and identified that the garage was converted into a staff office. This was also confirmed and documented during the pre-licensing inspection conducted on 2/26/2016. During today’s visit, the LPA conducted a physical plant tour at 9:35am. At 9:41am, the LPA observed the garage/office, and observed office equipment and some old resident furniture. The LPA did not observe a bed or any other furniture to indicate that staff were sleeping in the garage/office space at the time of observation. At 9:44am, the LPA observed the dedicated staff room, where the live-in staff sleep. Staff denied that they ever slept in the office and confirmed that they slept in their designated room. Based on the information obtained, there is insufficient evidence to support the claim that the garage was converted to living quarters. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: uncleared staff providing care and supervision to residents It was alleged that Staff #1 (S1) was not cleared to work at the facility. The LPA audited the facility clearance list and found S1 to be cleared and associated. After further review of the online caregiver background check system, it revealed that S1 had been associated to the facility since 6/10/2019, which was before this complaint was filed on 5/22/2020. During today’s visit, the LPA verified that the current staff working at this facility are cleared and associated. Based on the information obtained, there is insufficient evidence to support the claim that uncleared staff were providing care to residents at this facility. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. The LPA called Ms. Mastov and explained the findings. Mr. Mastov signed the report. Report emailed to the licensee.