complaint·September 30, 2025

Allegation: Staff do not meet incontinence care needs of residents. It was alleged that staff do not meet incontinent care needs of the residents (they are forced to sit in diapers full of feces for more than an hour) due to lack of caregivers. Interviewed staff denied the allegation. They stated that the facility has sufficient staff to meet all residents’ needs including incontinence residents. They stated that facility has enough staff to provide adequate care to residents in care. They assist residents with all their needs including diaper change. Facility has a 3-shift scheduled for morning, day, and night. They stated if there is a call off, they will replace the shift. It will be facility staff to work an extra shift, or facility will use staffing agencies to cover the shift. There are also student nurses on the floor almost every day. Interviewed staff stated that residents changed promptly, which is every 2 hours and as needed. If residents are soiled due to incontinence, they are changed right away. They are never forced to sit in diapers full of feces. LPA interviewed 8 residents of which 5 are incontinence. 4 residents stated the staff check their diapers often and change them as needed. 1 resident was unable to answer questions due to cognitive impairment. While LPA walked around to conduct resident interviews, LPA observed enough staff assisting residents. Also students from medical schools were present, assisting residents. Review of staff roster, daily staffing log, caregivers schedule and daily assignment sheet, indicates that the facility has sufficient staff to meet the needs of residents. Allegation: Staff do not dispense medications as prescribed. It was alleged that staff do not dispense medications as prescribed. A capsule was observed on the floor and the medication cup with a pill left in it. Interviewed staff denied the allegation. They stated that residents are receiving their medications as prescribed. Interviewed staff stated that medical staff dispense medication as prescribed. They stated that all nurses pass / administrate medications that are prescribed by doctor, there is no other way. Interviewed S1, S2 and S4 stated medications are popped up by LVN/ Med Tech before being administrated and given to residents by the staff who prepared the medication. If resident asks for medication to be left at his/her side that they can take independently, the staff / nurse will place the medication on the table in front of resident and remains at side of resident watching that resident swallow the medication. Staff does not walk away and leave the medication cup with a pill / medication in it. If they interrupted while popping medication, they will put the medication in the med. cart and lock it. Continue 9099C Interviewed S1 mentioned that approximately one year ago they found Tylenol on the floor in one of resident room, the family member that was present stated the medication was theirs and that they had dropped it when taking their daily medication. This is the only case that happened at the facility. Interviewed S2 - S7 stated that they didn't notice / found any medication / capsule on the floor / residents room. Residents interviewed were unable to corroborate the allegation. LPA reviewed medications for 6 residents. Those are being locked in the med. carts, administered as prescribed and indicated on the electronic Medication Administration Record (MAR). Although the allegations 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. Exit interview conducted and a report was provided to Selene Rangel- DHS.