complaint·April 1, 2025

Allegation: Staff do not ensure that facility is free of pests It was alleged that facility has bed bugs and cockroaches. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that she was aware of the problem and the facility had already hired a pest control exterminator to take care of the issue. Additionally, six (6) out of twelve (12) residents interviewed informed LPAs that the facility used to have bed bugs and once it was addressed the facility hired pest control. Although the residents interviewed could not confirm any recent evidence of bed bugs, they all confirmed seeing cockroaches at the facility bathrooms and common areas. Moreover, during the physical plant tour, at approximately 11:40am, LPAs observed a cockroach on the wall, by the business office and visiting room. Therefore, based on interviews, record reviews and LPAs observation, this allegation is Substantiated. Deficiency cited during today's visit. Exit interview conducted, appeal rights explained and copy of this reports signed and delivered. This complaint investigation was conducted by Douglas Real, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews, conducted between 11/14/24 to 02/01/25 with the Administrator, Caregiver Supervisor, Weekend Supervisor, three (3) staff members and R1’s Power of Attorney (POA). Investigator also attempted to interview R1 on 02/01/2025. In addition, the Investigator subpoenaed R1’s Medical Records on 11/14/24 and received a copy on 12/03/24. Allegation: Staff neglect resulted in a resident sustaining a pressure injury The investigation finding revealed that R1 had been living at this facility since 07/16/19 and was diagnosed with Dementia. Interview with the Administrator revealed that R1 was eating and drinking less and was less engaged with caregivers. R1’s family was aware of R1’s changes in condition and on 10/12/24, R1 was sent to the hospital. Administrator also informed the Investigator that R1 had no prior skin breakdown issues, but the Weekend Supervisor (WS) informed the Administrator on 10/12/24 that R1 had a possible pressure injury on sacral area. However, after the Administrator received a picture (via text), she observed R1 may have bumped his/her bottom and or scratched him/herself leading to the small open wound. Interview with the WS corroborated the statement provided by the Administrator. Furthermore, interview with the Caregiver Supervisor (CS) revealed that two (2) days before R1 was sent to the hospital (on 10/10/2024) CS found a small open scratch on the R1’s bottom (sacral area). The following day (on 10/11/2024) CS checked on R1 and saw the skin around the open wound was discolored and appeared as a bruise. Due to the change of skin color around the open wound caregivers began turning R1 every two hours and noted when they rotated R1 on a reposition log. Investigator also conducted interviews with three (3) staff members who denied the above allegation and informed the Investigator that they did not observe any staff members neglect or harm any of the residents. All parties interviewed, also informed the investigation that the facility staff provide an appropriate level of care and supervision to the residents. Moreover, interview with R1’s POA revealed that the facility notified him/her of redness to R1’s bottom the day R1 was taken to the hospital. POA expressed no concerns regarding the above allegation. Lastly, review of R1’s hospital records revealed that R1 was seen in the hospital and admitted on 10/12/2024 due to weakness, decreased food/water intake, and decreased responsiveness. Upon admission R1 was identified as having a stage II pressure injury on sacral area. R1 was treated at the hospital and discharged to a Skilled Nursing Facility (SNF) on 10/16/2024. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff mishandled a resident's personal belongings It was alleged that R1’s glasses and dentures were missing. To investigate this allegation, LPAs conducted an interview with the Administrator (during the initial visit on 10/28/24) and were informed that she’d worked here since February 16, 2021, and doesn’t recall ever seeing R1 wear glasses nor dentures. LPAs were also informed that R1’s family frequently visited R1 and brought new clothes and took the old clothes without notifying the facility and or updating the Client/Resident Personal Property and Valuables (LIC622). Administrator also stated missing/found items are taken to the donation room by all staff. Moreover, three (3) staff members interviewed denied the above allegation and informed LPAs that they did not see R1 use glasses/dentures. LPAs also conducted interviews with six (6) out of twelve (12) residents, who were able to communicate, and all residents interviewed expressed no concerns regarding this allegation. Residents informed LPAs that they know to report missing/stolen items to the front desk or to any staff member and an investigation will be conducted. Most residents misplace items, and they are later found. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.