complaint·October 26, 2023

During subsequent visit conducted on 10/26/23 LPA Tena Herrera obtained copies of staff and resident rosters and copies the following documents for R1: Face Sheet, Physcian’s Report, Replacement Appraisal, order from doctor indicating resident needs higher level of care, Acknowledgment of Discharged signed by responsible party, Inventory of Personal Items (upon discharge) and Signed Theft and Loss Policy. Conducted 7 staff interviews and 11 resident interviews. LPA attempted to interview R1 but they are no longer a resident at the facility as of 11/1/2022, LPA left voicemail for a returned call in the am and tried again twice in the afternoon with no success in reaching R1. Investigation Revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that staff are mismanaging R1’s medication as sometimes staff fail to administer medications to R1. Interview with S7 revealed that at times R1 would return from being out in the community intoxicated and because of this sometimes medication will not be administered as R1’s doctor would instruct MedTech’s to not provide dosage since medication cannot be taken while intoxicated or with alcohol. Interviews with MedTech staff and those who held a previous position as MedTech each stated that medications are never intentionally refused to residents. Interviews with residents 10 out of 11 residents denied the above allegation and stated that they are given their medication on time, have never been denied their medication, and feel the staff are doing a good job with their medication management. During visit LPA toured medication room, reviewed MAR and 5 residents medications, no issues were observed. Allegation: Staff failed to safeguard resident's personal belongings. It is alleged that S7 entered R1’s room and went through their personal belongings and after this the personal belongings went missing. LPA interviewed S7 and it was revealed that on one occasion while R1 was at a nursing home R1’s responsible party came to collect clothing for R1 and refused to sign the Inventory for Personal Belongings log, upon return to the facility R1 claimed that they were missing clothes but couldn’t provide specifics as to what was missing just stated that they knew they had more clothing. On another occasion R1 claimed a cologne was missing, after searching for the missing item, it was found have fallen behind R1’s dresser. Based on interviews with staff 7 out of 7 staff stated they do not handle residents belongings unless the resident asks for assistance, the only staff that does handle residents belongings is the Laundry Staff. (Continued on 9099-C) Based on interview with laundry staff S4 stated they only do washing for 2 residents at a time to avoid confusion and mix up of items, there is a list they go by when doing the laundry to ensure accuracy. Based on interviews with residents, 9 out of 10 residents stated that they have never had any of their personal belongings go missing. Allegation: Staff failed to treat resident with dignity and respect. It is alleged that staff does not treat R1 with dignity and respect as R1 feels that staff have forcefully attempted to send them to Skilled Nursing Facility (SNF) in efforts to “get rid” of them. Based on interviews with staff 7 out of 7 staff stated that they have never forcefully sent residents to SNF’s. Interviews with S1 and S7 revealed that residents are not sent to SNF’s directly from facility, if they have a medical condition in which they are hospitalized the doctor at the hospital will refer them to a SNF for rehabilitation before them returning to the facility. Based on interviews with residents 10 out of 11 residents indicated that they have never forcefully been sent to the hospital or SNF. R2 indicated that they were once sent to a SNF and didn’t want to go, however, this was done through the hospital doctor after R2 suffered injuries from a fall and does not feel they were forced, understood that it was best for their recovery. Allegation: Staff confiscated resident's wheelchair. It is alleged that R1 used to have an electric chair and one day it went missing and staff put it in a room called the “beauty shop”. Based on interviews with staff 7 out of 7 staff stated that they have never taken a residents wheelchair nor have they seen/heard of another staff doing so. In interview with S7 they stated that on occasion R1 would borrow other residents electrical wheelchairs and staff would have to remind residents to not lend or borrow each others belongings to avoid any issues. Based on review of records, upon discharge from the facility R1 was given all his belongings with wheelchair included. Interviews with residents 9 out of 11 residents interviewed denied the above allegation and stated that staff has never taken their wheelchair, walker or cane from them. Based on statements and interviews conducted with staff and residents, review of R1 files and medication review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.