Complaint·January 10, 2024

Resident was unable to provide LPA the contact information for PT and LPA was unable to interview. LPA interviewed a staff member from the maintenance team in which they stated there was a very small bubble in the flooring of the bathroom. Staff stated they don’t believe it was a tripping hazard but they did replace the whole bathroom floor. LPA observed a receipt from an outside agency for 10/4/23, in which company replaced the entire bathroom floor. LPA reviewed the work orders from maintenance, in which it shows the staff became aware of the flooring issue on 09/21/23. LPA interviewed the Health Services Director in which she stated she was unaware of any fall or trip hazard in resident room. LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff attempted to administer a medication that fell on the floor to a resident in care.” LPA interviewed resident in which they stated a medication technician (med tech) was dispensing their medications in the dining room. Med tech dropped resident pill on the ground and then proceeded to wipe off the pill and offer resident their medication. Resident was unable to provide LPA the name of the med tech. LPA interviewed health services director and she stated staff informed her that one time med tech handed resident their medications and resident dropped it on the floor and then resident picked it up off the ground and resident took it. Due to conflicting information LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff did not keep facility free of mold.” LPA interviewed resident in which they stated that there was mold in their shower. Resident informed the maintenance team and they confirmed the mold and removed it. LPA interviewed maintenance staff in which he stated he did observe mold in resident room, but he did observe dirt in the shower divider. Staff stated they cleaned the area and replaced the shower divider. LPA toured the facility and did not observe mold in the facility. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED. Continuation on 9099-C. LPA investigated allegation, “Staff did not respond to resident's request for a meal replacement.” LPA interviewed resident in which they stated there were many issues with the kitchen. Resident stated many times the kitchen staff did not serve them the food they ordered. Resident stated they are allergic to melon and strawberries and the fruit was served to them on multiple occasions for breakfast. The kitchen staff refused them a meal replacement and just grabbed the melon from their plate instead. LPA interviewed kitchen staff and they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced their food with no melon on their plate. Kitchen staff did not recall a time where staff grabbed the melon off the plate and refused a meal replacement. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview conducted. If the issue required a 3 rd party, it did take longer than normal. LPA reviewed the work orders, and observed 18 completed work order tasks. All work orders were completed within a few days or within the week. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Facility is in disrepair.” LPA conducted a file review, interviews, and toured the facility. LPA interviewed the resident in which they stated there were many issues with the maintenance of the facility which included the doors not locking properly, the garbage area, elevator, and their room having multiple issues during their stay. LPA toured the facility which included resident room, common living spaces, kitchen, elevators, and dining room. LPA observed the facility to be in good repair. LPA reviewed the work orders and found resident had 18 work orders while residing within the facility. All work orders were resolved. LPA observed that there were several maintenance issues that came up, however all issues were resolved in a timely manner. Due to the information gathered LPA finds the allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. LPA interviewed kitchen staff in which they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced her food with no melon on their plate. Kitchen staff stated resident’s allergy to melon was not listed in the dietary restriction binder in the kitchen that lists diets and allegories. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview conducted and appeal rights provided.