complaint·February 6, 2025

R3 declined to be interviewed. Three (3) staff were interviewed, and all reported they have never observed residents wear two (2) briefs at a time and had knowledge some residents request to add an incontinent pad to their brief. A witness interview was conducted with R1 and R2’s physician who reported they have never observed any residents at the facility wear two (2) briefs or report they are forced/encouraged to double brief. R1 and R2’s physician added they are not aware double briefing causes any medical issues or increases the risk of skin breakdown. R1 and R2’s physician reported for the past five (5) years they have never observed or suspected any of their patients residing in the facility to be neglected by facility staff. Regarding the allegation, “Staff chemically restrained resident” it was alleged on an unknown date, facility staff chemically restrained Resident 4 (R4) by administering a specific supplement after breakfast. R4 declined to be interviewed. LPA reviewed R4’s Physician's Report (LIC 602A) dated 5/23/22 noting R4 has the capacity to communicate their needs and administer their own Pro-Re-Nata medications. LPA also reviewed R4’s Medication Administration Record (MAR) for December 2023, which listed the supplement in question to be administered as needed at bedtime. One (1) of three (3) staff interviewed reported being authorized to dispense medications, refuted the allegation, and reported the supplement in question is only dispensed at night and at the request of R4. Two (2) of three (3) staff interviewed reported they have never suspected facility staff are over medicating residents or not following medication orders. Regarding the allegation, “Facility has an infestation of bed bugs” it was alleged there is a bed bug infestation in R1’s room and the facility has not obtained professional pest control services. It was further alleged the facility attempted to treat the affected areas themselves but has been unsuccessful. R1 was interviewed and reported in the past, they experienced bed bugs in their room. R1 added they reported sights of bed bugs to the executive director who resolved the issue. R1 reported their room underwent treatment twice and the facility worked diligently to eliminate the bed bugs. The facility reported Western Exterminator Company (WEC) completed an initial inspection of the building on 7/27/2023. An agreement was signed between the facility and WEC on 8/4/2023 and WEC began ongoing treatments on 8/15/2023. LPA reviewed the facility’s Heat Treatments log which noted R1’s room received a heat treatment on 8/22/23, 11/13/23, and 11/27/23. LPA reviewed a proposal dated 12/8/2023, prepared by the Western Exterminator Company (WEC) addressed to the facility. The service specifications noted bed bug heat treatment to various infested resident rooms including R1’s. An interview with Maintenance Director (MD), Roy Hayes revealed the facility owns a heater to treat bed bugs and will immediately treat any areas reported to have bed bug activity in addition to canine bed bug inspections and chemical spray/heat treatments provided by WEC. MD Hayes also added the facility purchased new mattresses and protectors to replace the ones with bed bugs. LPA also reviewed receipts from Amazon (dated 12/5/2023) and Mattress Firm (dated 12/8/2023) noting the purchase of 14 mattresses and mattress protectors. ED McGuirk was interviewed and reported the facility purchased the same exact bed bug heater WEC uses, which allows the facility to immediately treat the affected areas while waiting for Western to become available to conduct an on-site inspection. Although the facility has experienced issues with bed bugs, they are taking appropriate steps to help mitigate the problem. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was reviewe and provided to ED McGuirk.