complaint·July 13, 2023

Pg.2 Resident developed pressure injuries while in care. On the allegation that ‘Resident developed pressure injuries while in care’; it is the complainants concern that a resident developed pressure injuries while in care. To investigate the allegation the LPA interviewed the resident’s responsible party (RP). The RP stated that the resident did not develop the injury while in care, and furthermore the resident was receiving care by a hospice agency. The LPA requested medical documents and conducted record review. The record review indicated that the resident was receiving care by a hospice agency. Based on the information received through interviews and record review, there is not sufficient evidence to support the allegation that the resident developed pressure injuries while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are sustaining falls while in care. On the allegation that ‘Residents are sustaining falls while in care’; it is the complainants concern that residents are sustaining falls. To investigate the allegation the LPA interviewed residents, staff, and administrator. Three out of three residents stated that they had not sustained falls. The LPA interviewed the staff #1 (S1)who stated that some residents are at risk of falls, however S1 stated that they monitor the residents while they are awake, and sometimes the residents get up in the early hours of the morning or night and they may sustain falls while trying to get up from the bed or go to the bathroom on their own. The resident's room has a night signal to ask for help when needed. The interview with the administrator revealed that two residents have sustained a fall within the last two months; the administrator emailed the Incident Report to the licensing department and informed the residents’ responsible parties of the falls sustained by the residents. Based on the information obtained through interviews, and record review, although there is sufficient evidence to support the allegation that two residents out of five residents sustained falls while in care, the falls occurred while the resident attempted to independently go to the bathroom either at night or early morning. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg.3 LIC 9099C... Pg.3 Staff are causing the residents to choke on food. On the allegation that ‘Staff are causing the residents to choke on food’; it is the complainants concern that residents are given food items that are difficult for residents to eat. To investigate the allegation, the LPA interviewed the administrator, who stated that one resident almost choked on a piece of a grape, and that 9-1-1 was called. The resident was able to spit out the grape and was ‘ok’ afterwards. Still 9-1-1 was called to have the resident checked out. Residents’ interviews revealed that they are ok with the meals being served to them. Based on the information obtained through interviews, although there is sufficient evidence to support the allegation that one resident almost choked on food, there is not sufficient evidence to support the allegation that staff are causing residents to choke on food. There were no other incidents recorded where a resident chocked on food. Therefore, this allegation is deemed Unsubstantiated at this time. Staff are not addressing the residents’ hygiene needs while in care. On the allegation that Staff are not addressing the residents’ hygiene needs while in care’; it is the complainants concern that residents are only getting two showers a week, and residents are not assisted in brushing their teeth. To investigate the allegation the LPA interviewed the residents, staff and administrator. The staff stated that home health provides assistance with showers, and hygiene needs to three residents, the other two residents receive assistance from facility staff. The administrator stated that some residents receive assistance with showers from home health staff, and some receive assistance from staff at the facility. The residents get two showers a week, and more if needed. The residents brush their own teeth for the most part. The residents’ interviews revealed that they get assistance from a person that comes to the facility to help them with their showers. One resident stated that they don’t need help with hygiene needs. Based on the information obtained through interviews, there is not sufficient evidence to support the allegation that staff re not addressing the resident’s hygiene needs while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg 4. LIC 9099 C... Pg.4 Staff do not have planned activities for the residents. On the allegation that ‘Staff do not have planned activities for the residents’; it is the complainant's concern that residents don’t get activities. To investigate the allegation the LPA interviewed residents, staff, and administrator. The residents, interviews revealed that they participate in birthday celebrations, holiday get-together meals, and get to do activities such as coloring books. The residents have an outdoor area to get fresh air. The LPA observed an activity where the staff seems to be having a dance activity with the residents. Based on the information obtained through interviews and observation, there is not sufficient evidence to support the allegation that staff do not have planned activities for the residents. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are being locked in the home. On the allegation that ‘Residents are being locked in the home’; it is the complainants concern that residents are being locked in their rooms. To investigate the allegation, the LPA interviewed two residents, staff and administrator. The two residents interviewed stated that they are not locked in their room. During the unannounced visits conducted by the LPAs, it has been observed that residents are sitting either in the living room, in their bedrooms, and occasionally outdoors. Administrator denied having residents locked up. Staff denied locking residents in their rooms. During the physical plant tour the LPAs noticed that the bedroom doors have knobs that cannot be locked from the outside of the room. The front and back doors to the facility were observed to have a signal system to alert if the doors are open. The LPAs observed residents exiting the to the backyard independently while the back door was unlocked, and the signal alarm was activated. Based on information obtained through interviews and observation, there is not sufficient evidence to support the allegation that Residents are being locked in the home. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are serving expired food. On the allegation of ‘Staff are serving expired food’; it is the complainants concern that staff are serving expired food to residents. On 01/11/2023, Licensing program Analysts (LPAs) Sandra Urena, and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at 09:20 a.m. due to deficiencies observed during the investigation of Complaint Control # 29-AS-20230103142731. While conducting an assessment of the foods in the pantry, the LPAs observed that a box of approximately 15 containers of Ensure Plus supplements had expired, with an expiration date of 11/ 01/2022 and 12/01/2022. The allegation was Substantiated, and corrected on the same day 01/11/2023, as Administrator agreed to throw away the expired food. Continues on Pg.5 LIC 9099C... Pg. 5 Staff are pushing the residents while in care. On the allegation that ‘Staff are pushing the residents while in care’; it is the complainants concern that residents are being pushed by staff. To investigate the allegation the LPA interviewed residents, staff and administrator. The residents’ interviews revealed that they have not had any staff pushed them. The Administrators stated that they have not received any complaints by residents or residents’ responsible parties about being pushed by staff. Staff denied pushing residents. Based on the information obtained through interviews and observation, there is not sufficient evidence to support the allegation that Staff are pushing residents. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are left soiled. On the allegation that ‘Residents are left soiled’; it is the complainants concern that residents are not being assisted with incontinence needs during the night. To investigate the allegation, the LPA interviewed residents about their incontinence needs being addressed by staff during the night. The interviews revealed that four out of six residents do not have incontinence needs, they are ambulatory, and two residents are being assisted with incontinence needs as needed. The LPA interviewed the administrator and the staff. The administrator stated that the staff check on the residents at night every two hours to see if they need assistance with incontinence needs. The staff stated that they check the residents every two hours, and change diapers as needed, but typically residents don’t need to be changed. Based on the information obtained through interviews, there is not sufficient evidence to support the allegation that residents are left soiled. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg.6 LIC9099 C... Pg. 6 Staff are not providing adequate care and supervision to the residents . On the allegation that ‘Staff are not providing adequate care and supervision to the residents’; it is the complainants concern that the night shift is done by one staff member and is not enough to supervise all residents, and residents getting injured due to falls. To investigate the allegation the LPA interviewed residents, staff and administrator. The staff interviews revealed that residents sleep through the night and for the most part and do not need assistance assistance at night. Three out of three residents interviewed stated that they have not sustained falls and do not need assistance at night. The administrator stated that sometimes residents who are ambulatory, do get up to use the bathroom at night. Based on the information obtained through interviews , there is not sufficient evidence to support the allegation that Staff are not providing adequate care and supervision to the residents . Therefore, the allegation is deemed to be Unsubstantiated at this time. Exit interview conducted. Today’s report was reviewed and issued.