complaint·December 27, 2023

(Continued from LIC9099) Outside sources interviewed did not corroborate the allegation, expressing no concerns in their observations of staff physically assisting residents, and not being informed by residents of rough handling concerns. Outside sources indicated that the language barrier and cultural miscommunications have resulted in misunderstandings. No records were found to support the allegation. The resident in question was unable to be interviewed. Regarding the allegation, "Staff did not meet resident(s) needs", it was alleged that staff did not respond to resident(s) call and/or provide assistance when needed. Staff interviews revealed that staff respond timely and frequently to resident requests and needs. Residents interviewed informed that staff assist them with their needs and respond when called. Outside source interviews were mixed, some sources stated they had no concerns, and other sources expressed concern regarding staff assistance during the night and follow through for therapies. No records were found to support the allegation. During three (3) unannounced facility visits, LPA directly observed staff members assisting residents when they heard the residents call out for assistance. LPA observed that staff did not always hear the residents call out every time, but once the call was heard, staff assisted within minutes. LPA spoke with the Administrators regarding how to ensure residents were heard on the first call. The resident in question was unable to be interviewed. Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff allowed resident(s) to remain in soiled briefs for long periods of time and double-diapered them. Staff interviews did not corroborate the allegation, staff informed that residents were changed 5-10 times per day, depending on individual needs and requests. Staff interview further revealed that for certain residents with more significant incontinence issues, an additional bed pad was used in the form of a second brief cut on the sides and laid flat on top of the bed. Resident interviews did not corroborate the allegation, residents stated they were assisted by staff with toileting and upon request. Outside source interviews confirmed observing that some residents were provided a second brief for incontinent issues, but noted that it was not done to keep staff from providing incontinence duties. Outside source interview further revealed observations of residents being clean and dry during facility visits, and residents being checked for incontinence throughout the day. No records were found to support the allegation. During three (3) unannounced facility visits LPA observed staff members assisting residents with toileting throughout the day; LPA observed the facility to be free from incontinence odors. The resident in question was unable to be interviewed. (Continued on LIC9099-C) (Continued from LIC9099-C) Regarding the allegation, "Staff did not administer medication as prescribed", it was alleged that staff administered a pro re nata (PRN) medication to a resident (R1) at intervals more frequent than the prescription allowed. Staff interviews did not corroborate the allegation, staff denied that PRNs were provided more frequently than the prescription, as the medications were audited by management weekly with no errors having been noted. Residents interviewed stated that they received their medications timely and correctly from staff. Outside source interviews did not reveal concerns regarding medication administration. Outside source interviews further revealed that the medication was prescribed to the resident and was administered within the prescription requirements. No records were found to corroborate the allegation. The resident in question was not able to be interviewed. Based on interviews, direct LPA observations and records review, the investigation did not yield sufficient evidence to conclude that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that they occurred. An exit interview was conducted with Administrator David Swagerty, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.