complaint·March 4, 2025

Interview with three (3) of three (3) residents indicated that staffs at the facility are ensuring that they are kept clean and dry at all times. Six (6) of six (6) staffs interviewed stated that they are checking on their residents at least every two (2) hours to make sure that they are kept clean and dry and every hour for other residents. Six (6) of six (6) staffs interviewed revealed that there's no incident at the facility that a staff did not ensure R1 was kept clean and dry at all times. During the facility visit on 12/05/2024 and 03/04/2025, LPA Brown observed staffs at the facility checking on their incontinent residents to ensure that they are kept clean and dry. Second allegation: Staff do not ensure resident receives colostomy care in a timely manner. The investigation was conducted by LPA Melody Brown which consisted of file review, observation and interviews with relevant parties. During the investigation, LPA Brown was not able to obtain sufficient evidence to support that staffs are not ensuring that resident received colostomy care in a timely manner. LPA Brown interviewed R1 and R1 indicated that staffs at the facility are ensuring that R1 receives colostomy care in a timely manner. In addition, R1 showed LPA Brown R1's colostomy supplies in R1's dresser top drawer during the facility visit on 12/05/2024. Interview with Six (6) of six (6) staffs indicated that they are ensuring that R1 receives colostomy care in a timely manner. During the facility visit on 12/05/2024, Staff # 1 (S1) and Staff #2 (S2) provided receipt of colostomy supplies that the facility purchased for R1 when R1's Home Health did not send the colostomy supplies for R1 to ensure R1 receives colostomy care timely. Third allegation: Staff do not ensure residents room is free of malodors. The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. The third allegation indicates that Staff do not ensure residents room is free of malodors. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. LPA Brown interviewed R1 and R1 indicated that staffs at the facility are cleaning R1's room two (2) to three (3) times in a day. In addition, R1 reported that staffs at the facility are keeping R1's room clean and free of malodors. Interview with three (3) of three (3) residents indicated that staffs at the facility are ensuring that their room is free of malodors. Interview with seven (7) of seven (7) staffs stated that they are making sure that all their residents room are kept clean and free of malodors. Seven (7) of seven (7) staff interviewed indicated that there's no incident at the facility that they did not keep R1's room clean and free of malodors. During the facility visit on 12/05/2024 and 03/04/2025, LPA Brown observed R1's room clean and free of malodors. ***Continuation in LIC9099C*** Fourth Allegation: Staff do not prevent other residents hitting resident in care. The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. During the investigation, LPA Brown was not able to obtain sufficient evidence to support that staffs do not prevent other residents hitting resident in care. LPA Brown interviewed R1 and R1 indicated that staffs at the facility are preventing other residents from hitting R1. Interview with three (3) of three (3) residents indicated that staffs at the facility are always supervising them to ensure that no resident will hit another resident. Six (6) of six (6) staffs interviewed stated that they are checking on their residents every two (2) hours, or every one (1) hour if needed to provide the needed care and supervision of their residents. Seven (7) of seven (7) staffs interviewed reported that there's no incident at the facility that a staff did not prevent a resident hitting other residents. Seven (7) of seven (7) staff interviewed revealed that there's no incident that a staff did not prevent other residents hit R1. During the facility visit on 12/05/2024 and 03/04/2025 LPA Brown observed staffs at the facility providing care and supervision to all their residents. Also, LPA Brown noted that staffs are checking on their residents to determine if a resident requires assistance and to ensure that a resident will not hit another resident. Fifth Allegation: Staff do not ensure residents are spoken to in an appropriate manner. The investigation was conducted by LPA Melody Brown which consisted of observation and interviews with relevant parties. The fifth allegation indicates that staff do not ensure residents are spoken to in an appropriate manner. During the investigation, LPA Brown was not able to obtain sufficient evidence to corroborate the allegation. LPA Brown interviewed R1 and R1 indicated that staffs at the facility are communicating with R1 with respect, that staffs at the facility never shouted at R1 and there's no staff that spoke to R1 inappropriately. Interview with three (3) of three (3) residents indicated that staffs at the facility are kind and always ready to help, and that there's no incident that a staff spoke to them inappropriately. Seven (7) of seven (7) staffs interviewed reported that they are respecting all their residents at the facility and there's no incident that a staff spoke to a resident or to R1 inappropriately. During the facility visit on 12/05/2024 and 03/04/2025, LPA Brown observed staffs at the facility communicating with their residents with respect and no staff are speaking to a resident inappropriately. ***Continuation in LIC9099C*** Therefore, based on the evidence obtained during the LPA Brown's investigation, there is insufficient evidence to prove that staff do not ensure resident is kept clean and dry at all times (Allegation #1), staff do not ensure resident receives colostomy care in a timely manner (Allegation #2), staff do not ensure residents room is free of malodors (Allegation #3), Staff do not prevent other residents hitting resident in care (Allegation #4), staff do not ensure residents are spoken to in an appropriate manner (Allegation #5) are UNSUBSTANTIATED at this time. Although the allegation of staff do not ensure resident is kept clean and dry at all times (Allegation #1), staff do not ensure resident receives colostomy care in a timely manner (Allegation #2), staff do not ensure residents room is free of malodors (Allegation #3), Staff do not prevent other residents hitting resident in care (Allegation #4), staff do not ensure residents are spoken to in an appropriate manner (Allegation #5) 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 at this time. An exit interview was conducted where this report (LIC9099), was discussed and provided to ED Brittney Martinez.