complaint·May 5, 2021

Allegation: Staff mismanaged resident's medication. Complaint alleged the facility was not ensuring resident's medications were being refilled timely. On 04/21/2021 LPA conducted a medication audit for three (3) residents in care. LPA compared the resident's medication list to their MARS sheet for the months of January 2021, February 2021 and March 2021. LPA observed no errors. LPA spoke to three (3) of five (5) residents in care who stated "as far as they knew, they were receiving their medications." Facility staff stated the Administrator handles medication orders. The Administrator stated they check medication supply at least once a day. When there is only a 7 day supply left of medications the Administrator will call into the pharmacy to refill the prescription. No further evidence could be provided. Allegation: Resident was not provided nutritious meals. Complaint alleged resident was not provided a nutritious meal by the facility staff during their residence. On 04/21/2021, 04/23/2021 and 04/30/2021 LPA interviewed three of three (3) staff who stated the facility provides three (3) meals a day with two (2) snacks in between. On 04/30/2021 in the afternoon, S2 stated the residents had the following for lunch: cooked chicken, fruit, macaroni salad, 3 bean salad, cranberry juice and water. On 05/03/2021 LPA reviewed facility menu provided which indicated the residents are being provided three (3) balanced meals a day. No further evidence was available for review. Allegation: Resident's bathing needs were not being met. Complaint alleged resident was only receiving a bath every four (4) days. On 04/21/2021 and 04/23/2021 LPA interviewed three (3) of three (3) staff who stated residents receive baths/showers every Sunday, when requested, and as needed. Staff also stated that between baths, staff will clean and wipe residents down to ensure they are odorless and dry. On 04/21/2021 and 04/23/2021 LPA interviewed three (3) of five (5) residents in care who stated they receive showers once a week, upon request and as needed. R5 stated they are independent and are able to shower themself. R2 stated they are cleaned in between their showers by S3. No shower records were able to be provided for review. LPA spoke with key witness on 04/29/2021 who stated during their visits R1 appeared to be well-groomed, showered, and odorless. ***Continuation on LIC9099-C*** Allegation: Resident was not provided clean linen. Complaint alleged resident did not receive clean linen for the time of their residence. LPA toured the facility on 04/23/2021 and observed resident's rooms and bedsheets. LPA observed rooms to be clean and in good repair. LPA found sheets to appear clean, dry and odorless. LPA observed the linen closet to be stocked with a sufficient amount of clean linens. During LPA's visit on 04/23/2021 LPA interviewed three (3) residents in care who stated the facility changes their sheets weekly and sometimes daily as need. On 04/29/2021 LPA interviewed a key witness who stated during their visits, R1's bedsheets appeared clean and dry. Allegation: Staff handled resident in a rough manner. Complaint alleged S1 handled resident in a rough manner when providing bathing. On 04/21/2021 and 04/23/2021 LPA interviewed three (3) of five (5) residents in care. Residents stated the staff treat them well and take good care of them. On 04/21/2021 and 04/23/2021 LPA interviewed three (3) of three (3) staff who stated they have not witnessed residents treated in a rough manner by other staff. No further evidence could be provided. Allegation: Staff did not treat resident with dignity and respect. Complaint alleged S1 did not treat resident with dignity and respect when providing resident with a shower. On 04/21/2021 and 04/23/2021 LPA interviewed three (3) of five (5) residents in care. Residents stated the staff are "very good and very nice." On 04/23/2021 interview with S2 stated S1 would bathe R1. S2 stated they would assist S1 when bathing R1. S2 stated S1 would sit R1 in a chair in the shower and wash R1 with soap and shampoo and rinse R1 with warm water. S2 stated R1 did not state the water was too hot. S2 stated they did not witness S1 treat R1 with disrespect. Allegation: Staff did not ensure water temperature was appropriate for resident. Complaint alleged S1 did not ensure the water temperature was appropriate for resident when providing resident with a shower. On 04/23/2021 LPA interviewed two (2) residents in care who stated the shower water is warm and not too hot. Residents interviewed stated the water felt like the appropriate temperature. Interviews with two (2) of three (3) staff interviewed on 04/23/2021 stated they test the temperature of the water before washing the residents. Key witness stated on 04/30/2021 when they visited the facility they washed their hands in the bathroom sink and the water was warm and not too hot. On 05/03/2021 LPA reviewed facility's last annual inspection which shows the water temperature was last measured within the required range. Due to the above information, LPA finds the allegations listed above to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview conducted with Administrator, copy of report and appeal rights provided. Administrator to send a signed copy to LPA by 05/06/2021.