complaint·August 16, 2024

The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed records, toured the kitchen and interviewed 8 staff members which included the Executive Director, Memory Care Director, Cook, LVN, (2) MedTechs, Front Desk, and Care Partner. On 07/05/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to the facility listed above. LPA was met with Administrator, Michael Mendoza (S1), and later by Office Manager Tyshima Bonner (S2), and the purpose of today’s visit was explained. During today’s visit, LPA requested documents pertinent to the investigation. The following documents received include Staff Roster, Resident Roster, incident report(s), 4 months of past pest control invoice(s) and two (2) Admission Agreements. Allegation(s): Staff do not ensure that a resident's toileting needs are met. Regarding the allegation "Staff do not ensure that a resident's toileting needs are met,” it is being alleged that facility staff does not check on resident(s). Seven (7) out of (7) seven staff interviews, including the Memory Care Director, indicated that residents are checked on every two hours and they have not received complaints. Memory Care Director indicated that she has not seen any internal reports concerning toileting and that she tours the facility to speak with residents and there has not been any complaints. Seven (7) out of seven (7) resident interviews indicated that they do not have toileting complaints and that they are checked occasionally because of their independence. LPAs did not smell urine in the facility nor on the interviewees. Regarding the allegation “Staff do not ensure that a resident's toileting needs are met,” based on interviews and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff are not addressing pests at the facility. The investigation revealed the following: Regarding the allegation "Staff are not addressing pests at the facility,” it is being alleged that there are rodents in the kitchen and they have eaten through food products before. Record review reveals that the facility receives monthly pest control services of work completed and recommendations. Continue to LIC9099-C Interview with Accounting indicated that the facility has had pest control services since May 2020. Interview with the Executive Director indicated that traps are set but the facility hasn’t witnessed any rodents in the kitchen area. LPA toured and observed kitchen and storage closet. LPA saw multiple freezers and an organized storage closet with canned goods and items in plastic containers. LPA did not observe signs of rodents. Six (6) out of (8) eight staff interviews, including the Cook, indicated that they have not witnessed any rodents nor received rodent complaints. Six (6) out of (8) eight resident interviews indicated that they have not seen any rodents in the kitchen. Regarding the allegation “Staff are not addressing pests at the facility,” based on observation, record review, and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff do not answer a resident's call button in a timely manner. Regarding the allegation "Staff do not answer a resident's call button in a timely manner,” it is being alleged that facility staff does not respond for approximately twenty minutes. Seven (7) out of (7) seven staff interviews, including the Front Desk, indicated that calls are responded to in 5 – 15 minutes. Memory Care Director indicated that residents know how to call the receptionist’s desk if resident thinks there is a problem with his/her call light. Six (6) out of (8) eight resident interviews indicated that staff responds within 3 – 10 minutes. Regarding the allegation “Staff do not answer a resident's call button in a timely manner,” based on interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Continue to LIC9099-C. Allegation(s): Staff do not monitor a resident for change in condition. Regarding the allegation "Staff do not monitor a resident for change in condition,” it is being alleged that the Licensee did not provide additional staff assistance to Resident #1 (R1) when transferring to their wheelchair on 08/11/22. R1’s Assisted Living Waiver (ALW) assessment on 10/20/21 and on 12/06/23 does not reveal that R1 needs more than one person for transfers. Interview with the Executive Director indicated that the ALW Program sends a representative out every six months to complete an individualized service plan (ISP) and ALW determines the tier level for each resident and covers the cost. Record review also revealed that R1’s physician’s report was completed on 01/25/24. Regarding the allegation “Staff do not monitor a resident for change in condition,” record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Michael Mendoza.