complaint·January 30, 2025

The investigation revealed the following. Regarding Allegation: Staff are unable to provide adequate care and supervision for the residents during a power outage- It is alleged facility staff were unable to provide adequate care and supervision during a power outage on 12/24/2024. Resident interviews revealed on 12/24/24 the facility experienced a massive power outage from 1:30pm till 2am on 12/25/2024. According to the facility Emergency and Disaster Plan for residential care Facilities for the Elderly (610E), the facility emergency plan indicates “Back generator will automatically operate in case of an emergency power shut off. The generator is southwest of the building in the patio area. Facility is also equipped with flashlights. There will be a rotation and residents will be assigned with care members who will be constantly checking on residents and their needs.” Resident interviews revealed the facility automatic generator did not automatically turn on when the power went out. Resident interview revealed R2 lit a candle in their room as a source of lighting. Six (6) out of eleven (11) residents interviewed revealed staff did not check-in them constantly during the power outage. Nine (9) out of the nine (9) staff interviewed denied this allegation. Staff interviews revealed the facility automatic generator has been in disrepair and did not automatically turn on when the power went out. Staff revealed the facility did have two (2) portable generators on site but, staff was only able to get one (1) of the generators running. This portable generator powered hallway lights in the facility 2 nd floor, 3 rd floor, temporary string lighting in the dinning room and some oxygen machines if needed. Resident interviews revealed they were left in the dark while in their rooms, but the dinning room and front entrance of the facility was equipped with portable lighting. According to staff interviews, since the emergency pull cords were not functioning, residents that had cellphones had to call the front office cellphone for assistance. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed the facility generator located in the southwest of the facility to be in disrepair. As a result of the automatic generator being in disrepair, residents were left in the dark in their rooms with no heating, several staff were observed to be using their own cellphones to provide lighting while they worked, and emergency pull cords were not functioning, and residents that had cellphones had to call the facility front office cellphone for assistance. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. One (1) deficiency was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided via email. Staff allowed residents to be soiled while in care- It is alleged facility staff allowed Resident#3 (R3) to remain soiled during the power outage. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. R3 denied this allegation during interview. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez toured resident rooms and observed resident beds to contain proper linen. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff did not meet a resident's hygiene need while in care- It is alleged staff did not meet residents’ hygiene needs. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez observed sufficient hygiene supplies in the facility supply/stockroom. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff did not provide adequate food service- It is alleged staff did not provide adequate food service during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Residents revealed the facility provided them with a hot meal during the power outage for dinner and snacks later on in the evening. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff left a resident unattended- It is alleged staff left R3 unattended during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Interview with R3 revealed staff did not leave R3 unattended on 12/24/2024. R3 revealed staff did check in on R3, two or three times during the power outage. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. SEE 9099-C for continued report. Staff did not provide laundry services for a resident while in care- It is alleged the facility washing machines were in disrepair during the power outage. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Staff interviews revealed the laundry room was temporarily closed on 12/24/2024 from 2pm till 2am on 12/25/2024 due to the power outage, but the washing machines and dryers were not in disrepair. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed all washing machines and dryers to be operational. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff administered medication without proper consent- It is alleged staff administered R3 a medication without a physician’s order. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. LPA Ramirez reviewed R3’s charting notes for December 2024, Medication Administration Record (MAR) for December of 2024 and physician’s orders. LPA Ramirez did not observe any discrepancies. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.