complaint·June 20, 2024

The investigation revealed the following. Regarding Allegation: Staff neglect led to resident sustaining pressure injury- It is alleged R4 sustained an pressure injury while in care due to staff neglect. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. LPA Ramirez reviewed hospice care plan that address wound care by hospice staff. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff left resident unattended in soaking wet diaper for extended periods- It is alleged R4 was left unattended soaking in wet diaper for extended periods of time. R4 was admitted into facility on 8/4/2021. R4 began receiving Hospice Care on 07/26/2023. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During facility tour, LPA Ramirez observed facility staff providing R4 with grooming needs in R4’s bedroom. LPA Ramirez observed R4 to be well groomed and R4’s room was not observed to be odorous. LPA Ramirez observed more than 40 unopened bags of adult diapers in facility supply closet and garage. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . SEE 9099-C for continued narrative report. Staff did not assist resident- It is alleged staff do not assist R4 at night and remove R4’s call button. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. During facility tour, LPA Ramirez observed R4 seated in a recliner in the living room. LPA Ramirez observed a 2in x 2in round-white and green call button pendant sitting on top of a side table next to R4. LPA Ramirez observed a green lanyard attached to pendant. Interview with R4 revealed R4 wears the pendant around their neck at night and will push the call button for assistance when needed. LPA Ramirez tested pendant and was observed to be in working order. During tour of resident bedrooms, LPA Ramirez observed four (4) cordless bed senor pads under resident mattresses. According to S2, these pads detect movement and alert staff. When staff hear the alert sound off, they will check in on the resident. LPA Ramirez observed these sensors to be in working order. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff mismanaged resident's medication- It is alleged staff mismanage R1’s medication by overmedicating R1. R1 was admitted into facility on 8/4/2021. R1 began receiving Hospice Care on 12/19/2023. Review of R1’s hospice plan of care, revealed facility staff were instructed to monitor medications and report to hospice staff. LPA Ramirez compared R1’s centrally stored medication to R1’s MAR for the month of June 2024. LPA Ramirez did not observe and discrepancies. LPA Ramirez observed MAR for June 2024, which staff logged “PRN” (as needed) medication for R1, was administered according to R1’s physician order. LPA Ramirez compared R2, R3 and R4 MAR against centrally stored medications, and did not observe discrepancies. Three (3) out of the three (3) staff interviewed deny this allegation. Two (3) out of the three (3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not treat resident with respect - It is alleged staff do not treat residents with respect. Three (3) out of the three (3) staff interviewed deny this allegation. Two (2) out of the three(3) residents interviewed denied this allegation. Due to cognitive impairments, LPA Ramirez was unable to interview R1. Hospice care narrative note dated 6/12/24, revealed hospice staff observed R4 to be well cared for and hospice staff did not have concerns during visit. During tour, LPA Ramirez observed two (2) staff providing care and supervision. LPA Ramirez observed staff to be courteous and professional while caring for residents. Although the allegation do not may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.