complaint·April 17, 2024

The details of the complaint alleged that the facility on 12/29/2022, left R1 in a soiled diaper because the facility is understaffed resulting in R1’s needs not being met. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not meet resident's incontinence needs. All staff (S1-S5) stated that all residents who are incontinent have personal care checks every two hours or more depending on the resident and their care plan. The staff also noted that R1 had a Personal Assistance Liaison assigned to R1 because R1 needed more one on one assistance. LPA examined the facilities PAL Approach Chart and Services log for R1 and observed that R1’s incontinence needs were being met and charted by staff with the date and times R1 needed assistance. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not meet resident's incontinence needs. Residents stated that they did not have any problems with the staff assisting them with their personal care needs; and that they were satisfied with their care and supervision at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not meet resident's incontinence needs. Although the allegation 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 allegation is Unsubstantiated . Allegation # 2- Staff do not meet resident's dietary needs. The details of the complaint alleged that the facility did not serve R1 breakfast or lunch on two occasions because the staff did not have the time to do so. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not meet resident's dietary needs. All staff (S1-S5) stated that R1 was served meals three times per day in addition to snacks, water, and other fluids throughout the day. The resident was never denied meals, according to staff. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not meet resident's dietary needs. Residents stated that they were happy with the care and supervision being provided to them, and that their dietary needs are being met. They also stated that they get more than enough food and fluids throughout the day from staff. Based on interviews, there is insufficient evidence to support the allegation that Staff do not meet resident's dietary needs. Although the allegation 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 allegation is Unsubstantiated . Report continued on LIC 9099-C Allegation # 3- Staff do not follow resident's physician's order. The details of the complaint alleged that the facility did not follow the resident’s physicians order because R1 had a stage 2 pressure ulcer to the coccyx area. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not follow resident's physician's order. All staff (S1-S5) stated that R1’s physicians order was followed by staff and that R1 had a Home Health Nurse that would come and take care of R1’s wound weekly. Staff stated that R1 was repositioned and assisted with ADL’s daily by staff when not assisted by R1’s Personal Assistance Liaison or the Home Health Nurse. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not follow resident's physician's order. Residents stated that any orders given by their primary care physician is followed by the staff and have not had any issues in this area. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Staff do not follow resident's physician's order. Although the allegation 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 allegation is Unsubstantiated . Allegation # 4- Staff did not provide resident with clean linen. The details of the complaint alleged that the facility did not provide the resident with clean linens. It is reported that R1’s bed was made although the sheet had a large urine stain on it. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff did not provide resident with clean linen. All staff (S1-S5) state that linens are washed and cleaned weekly for all residents. But staff also stated that if a resident has an accident and soiled the sheets, they are cleaned upon occurrence, and the bed is made afterwards with clean sheets. LPA interviewed R1-R10 about the allegation and 9 of 10 resident’s that were interviewed denied the allegation that Staff did not provide resident with clean linen. Residents stated that the facility cleans their linen weekly but if they were to have an accident and soil the sheets, they would be cleaned immediately . Based on interviews there is insufficient evidence to support the allegation that Staff did not provide resident with clean linen. Although the allegation 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 allegation is Unsubstantiated . Report continued on LIC 9099-C Allegation # 5- Staff punished resident for behavior. The details of the complaint alleged that the resident has behavior problems, and that staff punishes resident by placing resident in the memory care unit leaving resident to scream. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff punished resident for behavior. All staff (S1-S5) stated that the facility does not punish or discipline its residents because of behavior issues. They state that all residents are treated with dignity and respect and that those residents that have behavior issues are redirected with behavior modification and allowed to express themselves and given time to relax. Once they are relaxed, they are redirected to get involved with activities and other stimuli to control their outbursts. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff punished resident for behavior. Residents stated that the staff has never punished or disciplined them in any way. Moreover, they state that they have never heard the staff raise their voices at anyone while they have been living here. Based on interviews, there is insufficient evidence to support the allegation that Staff punished resident for behavior. Although the allegation 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 allegation is Unsubstantiated . Allegation # 6- Staff did not provide resident with housekeeping. The details of the complaint alleged that the facility failed to clean the resident’s room because there was food on the floor, and it was not known how long it had been there. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff did not provide resident with housekeeping. All staff (S1-S5) state that the residents’ rooms are given a thorough cleaning weekly. However, housekeeping checks the rooms daily to empty the trash or vacuum if needed. All deny that the facility is not providing the resident with housekeeping. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not provide resident with housekeeping. Residents stated that housekeeping comes daily and that they deep clean the rooms once per week. They further state that anytime they have an issue, the facility always resolves it in a timely manner . Based on interviews, there is insufficient evidence to support the allegation that Staff did not provide resident with housekeeping. Although the allegation 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 allegation is Unsubstantiated . Report continued on LIC 9099-C Allegation # 7- Staff do not ensure that resident is hydrated. The details of the complaint alleges that the facility does not ensure the resident is properly hydrated. On 04/17/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not ensure that resident is hydrated. All staff (S1-S5) stated that all residents are given fluids throughout the day and with each meal served. They further state that the facility has several water stations through the facility, a bistro that serves food and different beverages, and that water is provided to the residents in their room via a refrigerator. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not assist resident with bathing. Residents stated that the staff does assist them with grooming and bathing. The residents further stated that are happy with the care and supervision provided by the staff. Based on interviews there is insufficient evidence to support the allegation that Staff do not ensure that resident is hydrated. Although the allegation 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 allegation is Unsubstantiated . No deficiencies were cited. An exit interview was conducted with Ralph Balbin, Executive Director, and a copy of this report was provided.