complaint·August 27, 2024

LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff handles residents in a rough manner resulting in skin tears. LPA interviewed staff which revealed 3 staff felt S1 handled residents in a rough manner and several residents told staff that they did not want assistance from S1. LPA reviewed disciplinary records for S1 which revealed S1 had a corrective counseling documentation dated 01/10/2023 where a peer reported S1’s approach with residents was a concern, S1 could be intimidating in size and tone of voice. The facility had a documented discussion with S1 for prohibited conduct -Caring for resident in an unprofessional manner and speaking to a resident in an unprofessional or discourteous manner, S1 was re-trained in customer service, dementia care, and proper re-directing techniques. On 02/21/2023 an internal investigation was conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 was put on leave 02/21/2023 and was terminated based on the investigation and interviews from residents and staff for a violation of policy- prohibited conduct as of 2:45pm on 02/24/2023. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Facility staff using profanity towards residents. LPA reviewed records for S1 due to an internal investigation on 02/21/2023 conducted by the facility from 02/21/2023-02/24/2023 for allegation of elder abuse by S1. S1 admitted to using profanity when discussing a resident or care related conversations with other staff. Staff interview revealed staff heard S1 use profanity in front of residents. Based on the evidence this allegation is Substantiated. On the allegation: Facility staff does not wear gloves when preparing food. LPA De Leon interviewed staff which revealed staff 2 (S2) does not wear gloves when preparing food in the kitchen. Disciplinary records were reviewed on S2, S2 no longer works at the facility, and S2 was let go for other reasons. Based on the evidence this allegation is Substantiated . Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator. LPA De Leon conducted a subsequent visit to the facility on 08/23/2023. LPA collected additional records: staff schedules, resident roster and staff schedules for August 2023, Staff disciplinary records for 2023, and Call pendant logs. LPA conducted interviews with staff at 10:15am, 11:10am, 11:50am, 12:05pm, 1:05pm, 1:20pm, 1:40pm, 2:20pm, 3:30pm, and 4:15pm. LPA interviewed residents at 12:15pm, 12:30pm, 12:45pm, and 2:55pm. LPA De Leon conducted additional staff interviews on 08/24/2023 at 11:18am and resident interviews at 12:20pm, 12:40pm, 1:45pm, 2:12pm, 3:15pm, 5:00pm, and 5:05pm. On the allegation: Facility staff did not properly store food causing residents to have food poisoning. LPA conducted interviews with staff and residents which revealed some residents got sick from a meal served by the facility in 01/2023. The interviews conducted do no mention anything about food storage or food poisoning. The facility did not have any incident reports of food poisoning and none of the residents went to the ER for any type of food poisoning. LPA conducted unannounced visits on 01/20/2023 and toured the kitchen, all food was stored properly. LPA found no evidence to support food poisoning or improper storage of food by facility staff. Due to the lack of evidence to support this allegation it is deemed Unsubstantiated. On the allegation: Facility staff threatened to evict resident. LPA interviewed staff and residents which revealed no residents were threatened with eviction. According to staff interview a resident said a physical therapist not an employee of the facility told a resident that they needed to do the required physical therapy or could risk eviction if the resident didn’t do the rehab. Another staff said the physical therapist is stern to the clients about rehab and some residents do not like to hear it. Based on the evidence this was not a facility staff therefore the allegation is deemed Unsubstantiated at this time. On the allegation: Facility kitchen is dirty. LPA De Leon conducted an unannounced visit on 01/20/2023, toured the facility Commercial kitchen and did not find it to be dirty. LPA conducted interviews with 15/16 staff which revealed staff did not think the kitchen was dirty. Resident interviews revealed 11/11 had not seen the inside of the kitchen, but a resident reported that other residents had and those residents were impressed with the kitchen, so the resident would not think it would dirty, if other residents were impressed. LPA reviewed schedules for kitchen staff with job duties which revealed the kitchen could be short staffed at times. It was stated in interviews that when short staffed if something did not get done on a staffs shift, it was done by staff on the next shift. Due to the lack of evidence this allegation is deemed Unsubstantiated ay this time. Exit interview conducted and copy of report printed for Administrator.