complaint·February 19, 2025

Allegation: Staff does not administer residents medication as prescribed On 02/19/2025 LPA and LPM conducted a medication audit for three (3) residents. Resident #1 (R1) did have a discontinued medication with their currents meds but it has not been given to the resident since it was discontinued. Additionally, R1 was out of a medication but the facility is waiting for the refill.Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Lack of care and supervision resulting in residents sustaining multiple falls During the course of the investigation LPAs interviewed facility staff. Interviews with staff revealed that the facility does have a handful of residents who are a fall risk. All staff are aware of which residents are a fall risk as well as their care needs. LPA reviewed all Unusual Incidents Reports (UIRs) regarding falls from May 2024 to September 2024. LPA found no discrepancies with falls and that the facility documented the falls as required with follow ups as necessary. Additionally, LPA reviewed the Post Fall Evaluation for six (6) residents. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility is not following food preparation safety procedures On 05/22/2024 LPA Ratajczak and LPA Hiratsuka conducted staff interviews which indicated staff are trained on proper food preparation procedures. On 02/19/2025 LPA and LPM conducted a tour of the facility kitchen. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff serve expired and spoiled food to residents in care On 05/22/2024 LPA Ratajczak and LPA Hiratsuka conducted staff interviews. Staff interviews indicated they have not observed any expired or spoiled food. Additionally, 02/19/2025 LPA and LPM conducted a tour of the facility kitchen, which included looking at facilities perishable and non- perishable foods. LPA and LPM did not observed any spoiled or expired food. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of the report and appeal rights was left at the facility. Allegation: Staff handled resident in a rough manner.- Unfounded On 05/02/24 LPA Ratajczak conducted a case management visit to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 04/25/2024. That report indicated that Staff #1 (S1) allegedly used force to redirect a resident from another resident’s room. LPA interviewed the Executive Director (ED), Jerilyn Purol and S1. This resident was no longer walking and would crawl to get around the facility. On this particular day, S1 was redirecting R1 out of another resident’s bedroom. S1 and R1 were holding hands as R1 was crawling out of the bedroom. Interviews indicated it could have been perceived as if R1 was being dragged however because R1 ambulated by crawling, R1 would request that staff hold their hand for assistance. Based on information obtained through interviews and file review the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Allegation: Lack of care and supervision resulting in resident's sustaining pressure injuries. - Unfounded LPA conducted a record review for R2 who had documented pressure injuries. R2’s resident file indicated that although R2 had pressure injuries, R2 was receiving Hospice services. Wounds were being monitored and cared for my Hospice staff. Based on information obtained through file review the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Allegation: Facility is not providing incontinence care products. - Unfounded Interview with ED, Jerilyn Purol, revealed that the facility does not provide incontinence care products for residents. The facility does have a program called Personal Solutions. Residents can sign up for an auto-ship program where their personal products, including incontinence supplies, are shipped directly to the facility. Many families provide the residents with their incontinence care products and have them shipped to the facility from Amazon. Residents who are on hospice are provided with incontinence care products from the hospice agency. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Allegation: Facility is not addressing the pests issue. - Unfounded Interviews with staff revealed that they have seen cockroaches in the facility on occasion. During LPAs visit no pests were observed. Interview with ED, erilyn Purol revealed that the facility has Ecolab come out monthly. Facility keeps a binder with documentation of each of their visits. Some of the things that Ecolab has sprayed for are cockroaches, ants, files, silkworms and more. Based on information obtained through interviews and file review the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal rights was left at the facility.