complaint·September 2, 2021

Allegation: Resident sustained a fracture while in care. It is alleged Resident sustained a fall resulting in a fracture while in care. During this investigation, IB Investigator could not interview R1 as the resident has dementia and could not answer questions. Review of R1 medical records revealed R1 was hospitalized from 9/8/20-9/13/20, for respiratory failure, likely due to congestive Heart Failure. On 9/25/21, R1 was admitted to the ER for abnormal pain, nausea, vomiting, compression fracture and the ED stated R1 was positive for a Urinary Tract Infection which may have contributed to vomiting and falls and neglect was not identified. The Reporting Party for the complaint was not a direct witness of any neglect or witness to any falls but overheard facility staff complaining about staffing concerns that contributed to R1 fall. IB Investigator interviewed R1 Family Member and she denied any neglect and stated the facility does everything to ensure the safety of R1. All Staff interviewed denied any neglect of abuse of R1. Based on records reviewed and interviewed conducted they’re in insufficient evidence to support neglect by facility staff. Allegation: Staff mismanages resident’s medications. Regarding the allegation it is alleged Staff mismanages residents’ medications. During this investigation, it was disclosed that LPA Calderon interviewed S1 who confirms that R1 medications is taken care of by her med-techs and there is strict documentation for each resident as to what medication is given, how much is given and to which resident so that no mistakes are made. LPA Calderon interviewed S2 who also confirms no mistakes are made regarding resident’s medications. LPA Calderon interviewed R2-R10 all confirm that their medications are correct, given on time and that staff notes in their log books the time, date, type of medication and amount for each resident. LPA Calderon reviewed R1 medications and Medication Administration Record and did not observe any discrepancies. Allegation: Facility does not maintain adequate staffing to meet resident’s needs. Regarding the allegation it is alleged Facility does not maintain adequate staffing to meet resident’s needs. During this investigation, it was disclosed that LPA Calderon reviewed medical records for R1, reviewed incident reports and staff roster for the month of October 2020 and staff schedule. Based on review of the records the facility has a total of (2 of Caregivers, 1 of med techs, 1 of Nurses and 2 of Housekeepers) LPA Calderon interviewed S1 who provided staffing documentation and confirmed that she has adequate staffing to meet resident’s needs. LPA Calderon interviewed R2-R10 all confirm there are no issues with staffing, residents confirm that if they need help there is a staff member able to help or when they push the call button it takes minutes for a response. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A face to face exit interview was conducted with Administrator Miki Lamm, and a hard copy was provided by hand for records.