complaint·July 25, 2023

Based on interviews and observations, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. reporting that a resident in care was sent to the hospital. Based on interviews and record reviews, we have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. Staff member mismanages resident medications. It is alleged that staff mismanage resident medications. All staff deny that the resident’s medications are mismanaged. Resident interviews do not reflect residents in care have had a problems with their medications. LPA requested the Medication Administration Records, (MARS) for review. LPA reviewed the MARS for the residents in care and found the record did not display anything unusual. Staff failed to provide adequate food services. Resident interviews reflect that residents don’t have an issue with the food that is being served during meal time. Residents in care shared that there is always an ample amount of food. Resident can ask for seconds and if what is being cooked isn’t preferred there are alternatives offered. LPA walked through the kitchen for observation. LPA observed an operational refrigerator which included fresh fruits and vegetables, milk and juices in the amount appropriate for the number of residents in care. LPA observed the two pantries which revealed a number of canned goods with in good standing. Deep freezers held frozen meals, treats and meats appropriate for the number of residents in care. LPA was also present while lunch was being served and observed a clean cooking station and food being prepared and served according to regulation. Staff provided LPA with the monthly food menu to include a variety nutritional meals. It is alleged that the facility is unsanitary. During the visit, LPA observed the facility’s physical plant. LPA observed no obstructions of the pathways. The hallway did appear to be dark, but there are several light switches along the wall which adequately lights up the pathway. LPA observed the smell and fumes of cleaning products throughout the facility. Resident rooms contained all regulated furniture. Each room appeared clean and orderly. The kitchen area also appeared clean and orderly. Outside of the facility no obstructions observed. A patio included a shady area and adequate seating. Resident interviews revealed that staff cleans the facility frequently because they can smell the presence chemicals in use. During staff interviews, it was discovered that the facility is cleaned up to three times a day. In the mornings during Breakfast Administrators work on cleaning the resident rooms. This includes dumping trash cans, sweeping, removing clutter, making beds and cleaning the bathrooms. Please see LIC9099C It is alleged that the facility is unsanitary. During the visit, LPA observed the facility’s physical plant. LPA observed no obstructions of the pathways. The hallway did appear to be dark, but there are several light switches along the wall which adequately lights up the pathway. LPA observed the smell and fumes of cleaning products throughout the facility. Resident rooms contained all regulated furniture. Each room appeared clean and orderly. The kitchen area also appeared clean and orderly. Outside of the facility no obstructions observed. A patio included a shady area and adequate seating. Resident interviews revealed that staff cleans the facility frequently because they can smell the presence chemicals in use. During staff interviews, it was discovered that the facility is cleaned up to three times a day. In the mornings during Breakfast Administrators work on cleaning the resident rooms. This includes dumping trash cans, sweeping, removing clutter, making beds and cleaning the bathrooms. Insufficient staffing to meet resident needs. LPA was provided with the facility staff schedule which reflected that two staff members are present 7am to 6pm. One being an Administrator and the other a direct care staff member. The evenings 6pm to 7am are covered by another staff member. Staff interviews are consistent with the staff schedule. Resident interviews reflect that residents are able to get assistance in a timely manner. During LPA visit, LPA observed both Administrators present and two staff members. It is alleged that staff failed to provide a comfortable environment for the residents in care. During the visit, LPA observed that the facility appeared to be clean and orderly, free of obstructions. LPA observed the same of the residents’ rooms and hallways. LPA observed the temperature of the facility to be cool and comfortable. Resident’s rooms also appeared to be clean and orderly. Resident interviews did not support the allegation that the facility is not comfortable. Residents report feeling safe inside the facility. Staff interviews were consistent with resident interviews. Staff denied that a resident complained of the facility being uncomfortable or unsafe. It is alleged that a staff member sleeps while on duty. Staff reported that one staff member works during the evenings. According to Administrators, there have been no reports of the staff member sleeping during the shift. Staff also denied that they had ever went to sleep while on duty of the facility. Because the staff member who normally works in the evenings was not present during the visit, LPA is unable to interview her. One (1) Resident interview revealed that the staff member who works during the evenings does sleep during the shift. As he called out, and the staff member did not respond. This resulted in the resident having to call 911 himself. Due to conflicting statements and the inability to interview the staff member in question. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.