complaint·August 12, 2025

Allegation: Staff does not ensure residents are provided clean towels. It is alleged that over the weekend of Aug. 9, 2025 - Aug. 10, 2025, there were no clean towels for resident use. A total of 13 residents were interviewed, of which all denied the allegation. A total of 12 staff were interviewed. Staff interviews revealed that the facility has a contract with a linen service company that drops off clean linens twice a week. On August 1, 2025, the facility changed linen companies from Mission Linen to Braun Linen. Braun Linen drops off items [sheets/pillow cases, hand/bath towels, blankets, and kitchen linen supplies every Tuesday and Friday. Per staff interviews, there was never a linen/towel shortage during the transition of linen service. Staff denied the allegation and stated all residents were provided clean towels the weekend of 8/9/25- 8/10/25. Residents are provided towels that are to be kept in their bathroom for regular use. Staff interviews revealed that the facility has a large inventory of linens and towels, but has a housekeeping staff shortage, which sometimes causes resident requests i.e. additional towel delivery to rooms to be delayed. LPA inspected the laundry area and observed sufficient towels and linens in the laundry room and 5 large bins outside the laundry area that contained clean linens/towels. Allegation: Facility has unqualified staff dispensing medications to residents in care . It is alleged that due to staff shortages the facility has staff working double shifts, and kitchen staff are also working as med-techs. All the residents interviewed stated they do not know whether med-techs are qualified for the job. Staff interviews revealed that staff (S7) began working at the facility as a server and was promoted to medication technician in March 2025. Based on record review, the findings indicate that staff (S7) completed 8 hours of medication administration training on March 16, 2025. There are 15 med-tech employed at the facility. Record review confirmed all have completed medication administration training. Therefore, the allegation cannot be supported. Allegation: Staff does not ensure medications are dispensed as prescribed. It is alleged that approximately 2 weeks ago a staff tried giving resident (R1) a pink medication pill that is not prescribed to the resident. According to information obtained, the alleged staff was suspended. Staff interviews revealed that on 7/21/25, caregiver staff (S8) entered R1 and R14's room and placed a medication cup near R1, that contained a Tylenol pill that was given to S8 by S11 for personal use. Resident (R1) picked up the medication cup and told staff it is not their medication. Caregiver (S8) stated that they were wearing gloves when they entered R1's room, and placed the medication cup on R1's walker while they removed their gloves and did not administer the medication to R1. Med-tech staff (S11) said they administered to R14 their Rosuvastatin Calcium 20 mg tab. According to S8, they only placed the Tylenol medication there while the gloves were removed. However, staff (S8) is not a med-tech, therefore should not have handled any medications in a resident's room. Neither staff were suspended. This allegation was investigated on a previous complaint control # 28-AS-20250722151911, in which the allegation was substantiated. LPA was provided copies of proof of correction addressing the aforementioned allegation. Therefore, the allegation is not supported because it has been addressed. Allegation: Staff does not ensure residents incontinence care needs are being met in a timely manner. it is alleged that staff leave residents in wet diapers for extended periods of time. The complaint alleges staff do not change incontinent residents as required. A total of 13 residents were interviewed. One (1) out of 13 residents confirmed the allegation. Residents said they are checked and changed often by staff, but on occasion the residents are left wet due to staff shortages and later response times. Staff interviews revealed that residents are checked every 2 hours and are assisted with incontinence care if needed. All staff denied the allegation, and said they have no knowledge of resident concerns pertaining to incontinence care. There is not sufficient proof to support the allegation. Allegation: Staff was observed using smoking products while in the facility. The complaint alleges that facility employees have been seen smoking in the building. Based on staff and resident interviews, the facility has an outdoor patio area designated as the smoking area for residents. All residents and staff denied seeing any staff smoke in the premises. Staff interviews revealed that the facility is a smoke-free workplace for all employees, and prohibits smoking e-cigarettes and vapor cigarettes. Based on interviews, in the past there was a staff person that smoked, but they have not worked at the facility since early 2025. There is insufficient proof to support the allegation. 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 with Executive Director Jacqueline Cortez. A copy of the report was issued.