complaint·August 25, 2023

The investigation revealed the following. Regarding Allegation(s): Facility is not providing residents with keys to lock bedroom door. It is alleged the facility is not providing residents with keys to lock their accommodations due to the locks being in disrepair. On 7/17/23, LPA Ramirez, cited facility for not providing at least seven (7) residents with keys to lock their accommodation. The facility did not provide keys due to the facility locks being in disrepair. Plan of correction (POC) was submitted on 7/25/23 for deficiency. Although the facility submitted POC, it was noted that additional parts would be required to repair or replace some locks and the locksmith would return and repair or replace the locks. On 08/22/23, LPA Ramirez observed locksmith replacing and repairing locks to resident accommodations. As of 8/22/23, Administrator Mnoyan revealed most locks have been rekeyed and all residents that requested a key received a key and signed an acknowledgment of receiving key. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility is not serving meals in a timely manner. It is alleged that kitchen servers are taking thirty (30) minutes to bring out meals during dinning hours. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. Interviews with staff revealed that although the dinning room is open at 7:30 am, residents can arrive early and wait for their breakfast to be served. According to staff, residents that arrive early before meals times are served, may feel like their meals are taking longer than usual. Staff revealed to that most meals are brought out within 10 minutes of placing order. LPA Ramirez toured kitchen and dining room area during breakfast and lunch. At 11:41 am LPA Ramirez observed staff serving meals within 8 minutes at 1 table with 2 residents during lunch. 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 allegation is UNSUBSTANTIATED. Food being served is of poor quality. It is alleged the facility is serving poor quality foods to residents in care. On 8/22/23, LPA Ramirez observed kitchen area and dinning room during breakfast and lunch hours. LPA Ramirez observed facility walk in refrigerator thermostat to read 39 degrees F. LPA Ramirez observed perishable food inside walk in refrigerator to be sealed in containers. LPA Ramirez did not observe any deficiencies. Containers were labeled with date of expiration. LPA Ramirez observed facility cook heating spiral cut ham for lunch. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. 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 allegation is UNSUBSTANTIATED. See 9099-C for continuation. Staff do not prohibit resident from harassing other residents. It is alleged facility staff do not stop resident from harassing another resident. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) of the residents interviewed revealed R5 will repeatedly ask residents and staff for cigarettes. Three (3) out of the four (4) residents interviewed reported R5 is annoying but not harassing or violent. 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 allegation is UNSUBSTANTIATED. Staff allow residents use illegal drugs and drink alcohol in the facility. It is alleged facility staff allow residents to use illegal drugs and drink alcohol in the facility. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. LPA Ramirez toured four (4) resident accommodations. No health and safety risks were observed. Residents interviewed revealed that although they have never seen illegal drugs being used in the facility, they believe other residents go out of the facility and return intoxicated. 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 allegation is UNSUBSTANTIATED. Facility staff is not ordering resident medication on time. It is alleged that the facility is not ordering residents medications on time. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. LPA Ramirez reviewed R2’s medication record and medical file. Records review revealed that on 06/15/23, R2 saw their physician and the physician ordered 30 tablets of a pain reliever. However, once the order was received and processed by the pharmacy, the physician changed the prescription to the pharmacy and decreased the number of pills to fourteen (14). LPA Ramirez reviewed original prescription request for 30 tablets of pain medication on 6/15/23 and electronically revised prescription for 14 tablets that was sent to the pharmacy on 6/16/23. 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 allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Mnoyan. A copy of this report was provided.