Complaint·July 27, 2025

LPA conducted six staff (S1 – S6) and nine resident (R2 – R10) interviews and toured the facility. On 07/25/2025, LPA received five Residents Incident Reports, and Medication Administration Records for four residents. On 07/21/2025. LPA received Resident Roster (dated 05/29/2024) and Staff Roster. On 07/25/2024, LPA Martinez conducted a tour of the interior/exterior areas of the facility, conducted interviews, and obtained copies of pertinent documentation. NOTE: Resident #1 no longer lives at the facility and June 2024 call logs were unavailable. Allegation: Neglect/Lack of supervision. Regarding the allegation, “Neglect/Lack of supervision,” it is being alleged that staff does not provide care and supervision to Resident #1. Record review of Admission Agreement (Basic Services) revealed care and supervision as one of R1’s services. Nine out of nine staff interviews (S1 – S6, S8 – S10) indicated they have not received any complaints that staff neglects residents. Eight out of nine resident interviews (R2 – R10) indicated that staff provides adequate care and supervision. Regarding the allegation, “Neglect/Lack of supervision,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are not following resident care plan. Regarding the allegation, “Staff are not following resident care plan,” it is being alleged that Resident #1 requires activities of daily living but staff does not assist because of R1’s refusal. Record review of Care Plan (dated 07/11/24) revealed R1 requires maximum assistance for bathing, dressing, toileting, transferring, mobility, special care needs (safety checks and assistance with oxygen). R1’s hospice care plan revealed that R1 would receive two skilled nurse visit/week and one PRN visit week one. Services did not include skilled supportive nursing care. R1 was assigned two hospice aide visits (this week). The Hospice Aide Assignment does not indicate the completed tasks. Seven out of seven staff interviews (S1 - S2, S5 – S6, S8 – S10) indicated that they are knowledgeable of resident care plans to deliver services. S1 indicated that the care plan is printed and staff are required to review and sign. Seven out of eight staff interviews (S1, S3-S6, S8 – S10) indicated that staff provides adequate care and supervision. Continue to LIC9099-C. Seven out of seven staff interviews (S1 - S2, S5-S6, S8 – S10) indicated that they try to encourage residents to receive care services or have another caregiver provide the services at a different time. S1 indicated that a care conference is scheduled when a resident refuses services. S1 indicated that a reappraisal may be needed for a higher level of care. Eight out of nine resident interviews (R2 – R10) indicated that staff provides adequate care and supervision. Regarding the allegation, “Staff are not following resident care plan” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff is not ensuring resident is being fed regularly. Resident appears malnourished. Regarding the allegation, “Staff is not ensuring resident is being fed regularly. Resident appears malnourished,” it is being alleged that staff Resident #1 declines meal services because of the service cost and supplements with vitamins. Record review of R1’s Admission Agreement (Optional Services. Special Food Service) revealed tray service, a special food service, is charged after two days if the resident is unable, not willing, to come to the dining room. After two days, a fee of $0.00 per tray will be charged. This charge will be itemized at the end of the month. Residents who are unwilling to come to the dining room are not provided two days of tray service without charge. R1’s June 2024 and July 2024 Medicaid Ledger does not reflect food charges. On 07/25/24, interview with S7 indicated that R1 receives tray service for all three meals (breakfast, lunch, and dinner). On 07/26/25, seven out of seven staff interviews (S1-S4, S6, S9 – S10) indicated that alternative meals are offered to residents who decline food. S5-S6, and S8 indicated that staff tries to encourage the resident and come back to offer food two – three times. S1 and S8 indicated that the doctor will be asked to order supplements and if a resident refuses three meals then the resident will be sent to the hospital based on the doctor’s orders. Five out of eight staff interviews (S1, S3 – S6, S8 – S10) indicated that there is not a service cost for food delivery. S2 was unaware. S1 indicated that if the doctor orders food delivery for residents then it is communicated to the kitchen staff and there is no service charge. Five out seven resident interviews (R2 – R6, R8, R10) indicated that there isn’t a service charge for food deliver. R7 and R9 are unaware. Continue to LIC9099-C. Regarding the allegation, “Staff is not ensuring resident is being fed regularly. Resident appears malnourished” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are not responding to emergency call system in resident's room. Regarding the allegation, “Staff are not responding to emergency call system in resident's room,” it is being alleged that Resident #1 fell on 06/14/2024 and did not receive assistance because the system was ineffective. On 07/25/24, an interview with S7 indicated that when R1 pulls the call button, R7 communicates with the care team and they will check on R1. On 07/26/25, nine out nine staff interviews (S1 – S6, S8 – S10) indicated that staff responds to residents’ call system. S1 and S8 indicated that many residents use the phone to call the front desk. Six out seven of resident interviews (R2- R3, R5 – R7, R9 - R10) indicated that staff responds in a timely manner. R6 indicated that R6 uses the phone and it automatically calls the Front Desk. LPA Cloyd tested the phone and the Front Desk answered. R4 and R8 indicated they don’t use the call system. Regarding the allegation, “Staff are not responding to emergency call system in resident's room” based on observation and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are allowing resident to become intoxicated while on numerous medications. Regarding the allegation, “Staff are allowing resident to become intoxicated while on numerous medications,” it is being alleged that staff does not interfere because Resident #1 is independent. Three out three staff interviews (S3-S4, S6) indicated they have witnessed residents with alcohol on the property. S4 also indicated that S4 is unaware of which resident take medication, and that staff would intervene. S2 was unaware. S5 – S6 indicated that they would speak with Supervisor prior to handing out medication. Continue to LIC9099-C. S1 indicated that staff cannot determine if a resident is intoxicated unless the resident tells them. Then staff will call the doctor and ask if they should hold the next round of medication. S8 and S9 indicated they don’t encourage alcohol but will remind residents if they smell it on them or see it that they are on medication. R4 and R8 indicated they have not witnessed residents bringing alcohol into the facility. R6 and R9 have witnessed residents drinking alcohol. R2 - R3, R7 indicated alcohol is not allowed. R5 and R10 are unaware. Regarding the allegation, “Staff are allowing resident to become intoxicated while on numerous medications,” based on interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Staff are allowing surveillance cameras in resident's room. Regarding the allegation, “Staff are allowing surveillance cameras in resident's room,” it is being alleged that Resident #1 installed cameras in R1’s room. The facility does have an Electronic Monitoring Consent Form. S10 indicated that R1 did have a sign posted on R1’s door. S1 and S8 indicated that residents would sign a form or post a notice on their door about video recording. Six out nine resident interviews (R2 – R10) indicated they are unaware if cameras are allowed. Regarding the allegation, “Staff are allowing surveillance cameras in resident's room” based on interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Psych Tech/Wellness Coordinator Breanna Jones.