complaint·March 21, 2024

The investigation consisted of the following continued: A tour of the facility was conducted on 03/21/2024 at 10:23 am. LPA España interviewed Resident 1- Resident 5 (R1-R5). LPA España interviewed Staff 1-Staff 3 (S1-S3). LPA Espana requested and received the following documents: Staff and resident roster; SIR reports; dated weekly employee time schedule; RCFE license certificate; verification of first aid training; criminal record statement; verification of staff training; personal rights; client resident personal property and valuables; centrally stored medication and destruction record; identification and emergency information; physician's report; resident appraisal; admission agreement; home health agency (list of all who provide services to residents/contact information); daily notes/staff notes/facility notes (1-month records); records or procedures of eviction; records of all evictions (log records) of the past 1 month (30 days); records of diapers or pull-ups of all residents in the facility and other pertinent records associated with this complaint. The investigation revealed the following: Allegation: Staff behavior is preventing a resident from sleeping. Administrator Josephine Hauf was interviewed by LPA España on 03/21/2024 at 9:07 am. Administrator stated that the night shift is managed by the Administrator and that staff do not prevent residents from sleeping. Administrator mentioned a ratio of 10 residents to 3 staff members, with herself covering the night shift. LPA España interviewed Resident 1- Resident 5 (R1-R5). LIC9099 Continued LPA España interviewed Staff 1-Staff 3 (S1-S3). Of those interviewed, S1-S3 stated there were no issues with staff behavior or preventing a resident from sleeping. On 03/21/2024, Residents (R1-R5) were interviewed, with 3 out of 5 residents stating they had no issues with sleeping. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Allegation: Staff do not prevent the residents from arguing. On 03/21/2024, LPA España interviewed S1-S3. Of those interviewed, 3 out of 3 staff stated they stepped in to prevent residents from arguing and added that only one resident argues with them. On 03/21/2024 LPA España Interviewed R1-R5. Of those interviewed, 3 out of 5 residents had no issues with S1-S3, either during day or night shifts. 3 out of 5 residents also confirmed they did not engage in arguments with staff, nor did staff argue with them. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. LIC9099 Continued Allegation: Staff did not prevent a resident from falling out of bed. On 03/21/2024, LPA España interviewed Staff 1-Staff 3 (S1-S3). Of those interviewed, 3 out of 3 stated facility takes precautions to prevent falls, and two staff added that one resident did fall out of bed after declining staff assistance. Additionally, LPA España interviewed Resident 1- Resident 5 (R1-R5), of those interviewed 4 out of 5 had no issues with falls. Additionally,3 out of 5 residents also confirmed being checked by staff regularly. On 03/21/2024, LPA España conducted records reviews at facility. Daily notes/staff notes/facility notes (1-month records), which indicated no falls for any of the residents in the period between February 21 to March 20, 2024. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. Allegation: Staff is retaliating against a resident. On 03/21/2024, LPA España spoke to Administrator Josephine Hauf regarding the allegation, administrator Hauf stated that no residents were subjected to retaliation. LIC9099 Continued On 3/21/2024 LPA España interviewed Resident 1- Resident 5 (R1-R5) and Staff 1-Staff 3 (S1-S3). On 03/21/2024, LPA España interviewed S1-S3 who stated they had not retaliated against residents. LPA España interviewed Resident 1- Resident 5 (R1-R5), of those interviewed 3 out of 5 stated they had seen not retaliatory behaviors fromss staff. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is Unsubstantiated. No were no deficiencies cited at the time of visit. An exit interview was conducted with Mercedes Espino, Caregiver and a ha rd copy was provided.