complaint·December 11, 2024

Orders, Preplacement Appraisal, Individual Service Plan, Hospice file, Unusual Incident Reports & laundry schedule. Prior to this visit on 12/10/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained from the facility. At the time of this visit at approximately 11:10a.m., LPA Alvizar-Ettima and Wellness Director conducted a physical plan tour. 1.) Resident sustained multiple injuries while in care. It was alleged that facility resident #1 (R1) sustained multiple injuries resulted from falls. During interviews ED and other staff verified that R1 had a fall. However, they denied being neglectful in R1’s care. R1 was receiving hospice services. On 05/14/2024, they did have an unwitnessed fall and was sent to the hospital. After resident came back, their in-house care plan was updated to address fall prevention. Hospice visits were increased and additional three (03) extra hours were added for one-on-one supervision. Bed rails were ordered by hospice agency to prevent R1 from falling. Other residents interviewed had no issues or concern regarding their care and supervision provided in the facility. During this visit R1 was present at the facility. At (time) LPA attempted to interview R1, but no able. A review of the facility records verified the information revealed by the staff. There was no information on evidence available during this investigation to conclude that R1 sustained multiple fall injuries due to staff neglect. Therefore, based on observation, interviews and record review, the allegation is UNSUBSTANTIATED at this time. 2.) Staff did not safeguard resident's personal belongings. It was alleged that all R1’ clothing gone missing, and staff do not log any items in resident’s file. Staff revealed that when R1’s family members drop off clothes at the front office. Front office staff write R1’s name on it and document the personal belonging (clothing) in an inventory log. Interviews with eight (08) out of eighty-nine (89) residents confirmed the information that staff provided. Resident’s interviews revealed that they never had their items go missing and have no concerns regarding facility staff not safeguarding personal items. A review of facility Resident Personal Property and Valuables, Inventory of Personal Effects, Resident’s Clothing and Possessions documents indicate that staff logged R1 clothing. No supporting information was available during this investigation to verify the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. Continue on LIC 9099 -C 3.) Staff did not ensure resident was in clean clothing. It was alleged that R1’s clothing always has a strong smell of urine. During resident’s interviews, LPA observed residents to be clean, well-groomed, and not smelling like urine. Staff revealed that all resident’s clothes is washed based on their laundry schedule date. S2 indicated that R1’s clothes are schedule to be washed three time a week or more if needed. Other residents’ interviews revealed that staff always clan them up and wash their clothing. Resident denied having urine smell on their clothes. A review of facility laundry schedule confirmed the information provided by staff. No supporting information was available during this investigation to verify the allegation. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. 4.) Facility is malodorous. It was alleged that the facility has a strong smell of urine. During physical plant tour, LPA was not exposed to offensive odor of urine in the hallways, common areas, nor in resident’s room. Staff (S1) recalled providing daily services in R1’s room and did not observe any malodorous odor. Staff revealed that house cleaning is performed seven (07) days of the week and daily tidy of the rooms which includes removal of any unpleasant offensive odor. Resident’s interviews revealed that they have not been exposed to urine odor in their room or common areas. staff always clans their rooms and remove wet diapers pr dirty clothing and never have urine smell. No supporting information was available during this investigation to verify the allegation. Therefore, based on interviews and observation, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.