complaint·October 17, 2024

The investigation revealed the following : Allegation #1- Staff do not ensure urinary catheter is emptied for resident in a timely manner. The details of the complaint alleged that the facility admitted a new resident (R3) that wears a urinary catheter bag, and the care staff are neglecting to assist the resident with emptying the bag when it gets full causing the urine to leak all over the facility when the resident walks around causing the facility to smell of urine. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 7 of 8 staff denied the allegation that the Staff do not ensure urinary catheter is emptied for resident in a timely manner. 7 of 8 staff that were interviewed stated that the resident (R3) does not have a catheter but has incontinence issues. One staff had no knowledge of the resident. They state that the staff never neglects (R3) in any way. The resident is always assisted by the caregivers with bathing, showering, grooming, and changing R3s adult briefs, stated S1. LPA reviewed the Physicians Report (Dated: 10/30/2023) and it did not indicate that R3 had a urinary catheter. LPA reviewed the Weekly Shower/Laundry Schedule (Dated: 11/20/2023) and it indicated that the resident is scheduled to take daily showers and have their laundry cleaned daily as well. The majority (7 of 8) staff that were interviewed, indicated that the resident needs to be encouraged to take the scheduled showers, and that they assist the resident in taking the showers. LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that Staff do not ensure urinary catheter is emptied for resident in a timely manner. Residents stated that they have not noticed any urine in the hallways or a smell of urine in the facility because of one resident. They also state that they do not know if the resident (R3) has a catheter or not. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure urinary catheter is emptied for resident in a timely manner. 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 ensure resident receives assistance with activities of daily living. The details of the complaint alleged that the staff does not ensure the resident receives assistance with activities of daily living causing the client to smell of urine. In that they don’t make sure the client is bathed, groomed, and in fresh clothing. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure resident receives assistance with activities of daily living. All staff (S1-S8) stated that resident (R3) is assisted with activities of daily living that involve showering, grooming, and washing the residents clothing. They stated that although the resident has incontinence problems the resident is not neglected and that the caregivers are changing the residents’ adult briefs and assisting the resident with showering, daily. LPA reviewed the Weekly Shower/Laundry Schedule (Dated: 11/20/2023) and it indicated that the resident is scheduled to take daily showers and the residents’ laundry is done daily. They also state that the resident does need to be encouraged to take the scheduled showers but does assist the resident in maintaining R3s hygiene. Complaint Investigation Report continued on LIC9099-C LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that the Staff do not ensure resident receives assistance with activities of daily living. The majority (7 of 9) clients interviewed stated that they have not smelled any urine scents in the facility because of the residents’ incontinence issue and that the caregivers are assisting with the residents’ activities of daily living. They also state that they are always assisted with their ADLs when needed. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure resident receives assistance with activities of daily living. 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 #3- Staff do not ensure the facility is kept free of malodors. The details of the complaint alleged that the facility staff does not ensure the facility is kept free from very unpleasant smells, mainly urine. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure the facility is kept free of malodors . All staff (S1-S8) interviewed stated that housekeeping cleans the facility daily and it is free from odors. S1 stated that they do deep cleaning once a week, which includes mopping the floors, scrubbing the bathrooms, laundry cleaning and changing the sheets. For the hallways, we do the floors from 11:30pm-4:30am to treat common areas Monday through Saturday. Specifically on floors, high-touch areas, windows, and common areas such as table surfaces, etc., stated (S1). LPA interviewed residents R1-R9 about the allegation and 7 of 9 residents that were interviewed denied the allegation that the Staff do not ensure the facility is kept free of malodors . The majority (7 of 9) of the residents interviewed stated that the staff does ensure the facility is kept free of malodors; and they have not noticed any unpleasant smells in the facility. LPA did not smell any malodors in the facility. Based on interviews, there is insufficient evidence to support the allegation that the Staff do not ensure the facility is kept free of malodors. 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 do not ensure the facility is kept free of pests. The details of the complaint alleged that the facility does not ensure that the facility is kept free from pests. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure the facility is kept free of pests. Complaint Investigation Report continued on LIC9099-C All staff (S1-S8) interviewed stated that there were no concerning pest issues in the facility and that they have not seen any pests. S1 stated that they have semi-monthly inspections for roaches, ants, bedbugs, mice, and pigeons. Twice a year K9 inspection is done for bedbugs, they come out and if they’re found, they do treatment for them, stated (S1). Lastly, stated S1, K9 then does a follow-up about one week later to double check. LPA reviewed Pest Control Service Report (Dated: 09/08/2023-11/13/2023) and observed that the facility is actively treating and preventing any pest issues that may arise in the facility. LPA interviewed residents (R1-R9) about the allegation and 6 of 9 residents that were interviewed denied the allegation that the Staff do not ensure the facility is kept free of pests. The majority (6 of 9) of the residents interviewed stated that they have not seen any pests in the facility or their rooms. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure the facility is kept free of pests. 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 #5- Staff do not ensure medications are dispensed as prescribed to residents in care. The details of the complaint alleged that the facility staff does not ensure that the clients are receiving the correct medications as prescribed. On 11/20/23, from 09:00am-4:00pm, LPA interviewed staff (S1-S8) and residents (R1-R9) regarding the allegation. 8 of 8 staff (S1-S8) denied the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. All staff (S1-S8) interviewed stated that the med-techs are ensuring that the residents are dispensing medications as prescribed; and if any errors occurred it is recorded in the Medication Administration Record (MAR). S2 stated that there is a system in place in the E-Mar, that detects new medication and discontinued medication, which prevents a lot of medication errors. S2 also stated that when S2 is dispensing medication, S2 is required to ask the residents name before giving the medication to make sure it is the right medication for the resident. LPA reviewed the Medication Administration Records (Dated: 10/1/2023-11/1/2023) and did not find any discrepancies. LPA interviewed residents (R1-R9) about the allegation and 8 of 9 residents that were interviewed denied the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. The majority (8 of 9) of the residents interviewed stated that they have not had any problems with getting their medication. They also state that they always get the correct medication that is prescribed for them. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure medications are dispensed as prescribed to residents in care. 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 Jenni Gordon, Administrator, and a hard copy of the Complaint Investigation Report was provided.