complaint·February 4, 2025

LPA Lee interviewed 4 out of 5 residents who expressed no concerns about regarding staffing and during emergencies. Additionally, all three facility staff members denied the allegation, affirming that they assist residents with activities of daily living (ADLs) and any other needs, and they believe the staffing level is sufficient for emergencies. Furthermore, 3 regular visitors to the facility reported no concerns about staffing and confirmed seeing three staff members on-site. On 01/15/25, LPA Lee observed three staff members from 8:30 AM to 12:00 PM and two staff members from 12:00 PM to 3:55 PM. Based on interviews and statements gathered throughout the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that the facility housekeeping is not completed on a regular basis. The investigation involved reviewing records, interviewing staff, residents, and three regular visitors, as well as observations. Facility record showed that the facility has a cleaning schedule in place. In interviews with residents, 4 out of 5 residents stated they had no concerns about housekeeping and that their rooms are cleaned by the care staff. Additionally, 3 regular visitors reported that the facility appeared clean and expressed no concerns. On 01/15/25, LPA Lee toured the facility, inspecting residents' bedrooms, bathrooms, and all areas used by residents. All areas were observed to be clean, sanitary, and comfortable. The facility appeared well maintained, with no concerns noted during the visit and today’s visit. Based on the interviews and observations made during the investigation, LPA Lee was unable to corroborate the allegations. It was alleged that the facility is not following infection control. The investigation included a review of records, interviews with staff, residents, and three regular visitors, as well as observations. Facility records showed that the facility has infection control measures in place. In interviews with residents, 4 out of 5 resident stated that care staff wear gloves when assisting them with care and expressed no concerns, denying the allegations. 3 facility staff members were initially unable to explain the term "hygiene" until LPA Lee provided examples. Once clarified, staff confirmed that they wash their hands before and after assisting with incontinence care and wear gloves during this process. It was unclear if a language barrier contributed to the confusion. 2 regular visitors reported no concerns regarding infection control and stated that they have not witnessed any issues with the facility’s practices. On 01/15/25, during a facility visit, LPA Lee observed staff (S1) assisting resident (R1) with a transfer while wearing gloves, and then washing hands afterward. Based on the interviews and observations made throughout the investigation, LPA Lee was unable to corroborate the allegations. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted and a copy of this LIC 9099, report was provided to facility.