complaint·August 23, 2022

diagnosis. Resident 2 (R2) was admitted to the facility in 2018. Interviews with R2’s family stated that they did not suspect that the facility hastened the death of their family member and maintains that R2 died of natural causes. This allegation is therefore unsubstantiated. Allegation 2: Facility has insufficient emergency food supplies. LPA Bueno visited the property multiple times and observed it to have sufficient food supplies and emergency food supplies. This allegation is unsubstantiated. Allegation 3: Residents are left in soiled diapers for extended period of time. Resident interviews reveal that sometimes they may have to wait from 5 to 20 minutes to be changed because of the number of residents needing assistance at that time. Interviews with residents also revealed that residents think the wait time to be reasonable because of staff shortage. LPA Bueno observed that one staff working per shift. This allegation is therefore unsubstantiated. Allegation 4: Facility toilet is in disrepair. LPA Bueno visited the facility multiple times and found the toilets to be working. Witness interviews revealed that one of three bathrooms was not working for a week, but they were given access to the other toilets and the broken toilet was fixed within the same week. This allegation is unsubstantiated. Allegation 5: Staff stole resident's medication. Staff interviews reveal that they have not seen any staff take residents’ medications for any other purpose than administering it to residents. Witness interviews reveal that they noticed Resident 3’s (R3) as needed (PRN) pain medication intake increased, and they educated staff on how to assist R3 without having to give too many PRN pain pills in a day. LPA reviewed completed medication administration record (MAR) for centrally stored medication and PRN (as needed) for 5 residents. This allegation is therefore unsubstantiated. Allegation 6: Staff did not have proper training to provide care and supervision to residents in care. Former staff interviews revealed that they received 11 hours of training, including hands-on training in three days before separating with the facility in less than a work week. Staff interviews also revealed that a full week training is completed within the first week of a newly hired staff. LPA observed dementia staff training binder and module and monthly staff meeting agenda covering This allegation is unsubstantiated. Allegation 7: Staff did not follow residents’ care plan. Witness interviews revealed that staff are following care plan, specifically R3’s dietary care plan. Witnesses stated that the dietary plan was requested by R3 and was approved by their care team. This allegation is therefore unsubstantiated. Allegation 8: Facility does not have planned activities for residents in care. LPA Bueno visited the facility multiple times and observed books, magazines, and puzzles available for residents and visitors. LPA observed one resident completing a puzzle in the living room during a visit. LPA also observed that all residents had their own electronic devices for personal entertainment. LPA viewed the daily social activity schedule. Staff interviews confirm that two former residents participate in some social activities with staff. This allegation is unsubstantiated. Based on the available information, we have found the complaint allegations to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Dr. Manzoor Massey at the conclusion of the visit.