Complaint·July 30, 2021

On 11/04/19, LPA Kontilis observed a bird cage containing five (5) doves in the outside area between the administrator’s office and the main building. LPA observed the cage to contain bird feces and fruit in and around the cage with several flies and ants surrounding the cage. LPA found that the birds flutter around and food from their cage gets thrown to the ground outside the cage where ants were seen. LPA also observed bird feces in and around the cage with flies surrounding the cage. Based on the information obtained, the allegation that, “Licensee failed to keep the facility free of rodents and/or insects.” is Substantiated . Exit interview conducted, deficiency cited, and a copy of the report emailed to administrator. On 11/04/19, LPA Kontilis toured the facility and observed a large supply of personal hygiene supplies in a variety of sizes. Items were stored in two different storage areas accessible to staff . On 7/27/21, LPA Chavez toured the facility and observed a closet in the medication room containing over thirty (30) packages of diapers in a variety of sizes. Business Office Manager stated that they also keep a back-up supply in her office and incontinent supplies are available in resident rooms. LPA reviewed invoices for incontinent supplies purchased in September and October 2019. Facility purchased a sufficient amount of incontinent products in a variety of sizes to provide for resident needs. Based on the information obtained, the allegation that, “Facility staff failed to ensure there is an adequate amount of personal hygiene supplies to meet the residents' needs.” is Unsubstantiated. On the allegation “Licensee failed to ensure residents are accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.”, the complainant’s concern was that staff is cleaning the resident rooms while they sleep and this exposes residents to cleaning chemicals. Further concerns are that residents are waking during cleaning due to the chemical smell. To investigate the allegation, LPA Chavez interviewed staff and toured the facility, and attempted to interview residents. On 7/21/21, administrator emailed LPA with a housekeeping schedule showing the days of the week and shifts within a day, areas in the facility to be cleaned, and laundry days. At 4:32 pm, LPA spoke with administrator who stated that the facility does not keep a housekeeping log to record the staff who performed the duties, and the date, time, and location of cleaning and laundry, however, she stated that staff do not clean resident rooms while they are present. On 7/29/21, LPA Chavez interviewed staff who stated the NOC shift cleans common areas such as the hallways and dining room by mopping the floors, cleaning scuffs on the walls, disinfecting showers located outside resident rooms, and washing windows. Staff interviewed stated that NOC shift personnel “do not clean resident rooms unless the residents are already awake after breakfast.” Based on the information obtained, the allegation that, “Licensee failed to ensure residents are accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.” is Unsubstantiated. Continued on 9099C. On the allegation “The facility has an insufficient amount of staff to meet the residents' needs”, the complainant’s concern was that the facility is not adequately staffed to meet the resident’s needs. Complainant stated the facility often has only one or two staff members to assist the seventeen (17) residents at the facility who have dementia. Complainant was concerned that four (4) of the residents require a two-person transfer and may not be transferred in a timely manner, if staff is busy with other residents. To investigate the allegation, LPA interviewed staff and reviewed facility records , and attempted to interview residents. LPA reviewed staffing records and observed three (3) staff worked on the AM shift, three (3) staff worked on the PM shift, and two (2) staff worked on the overnight shift. On 7/27/21 and 7/29/21, LPA Chavez interviewed staff. Staff reported that they believe there is enough staff to meet resident needs. they stated six (6) residents who needed a two-person assist were on hospice, and hospice aides assisted during the week. LPA asked staff if they ever thought there wasn’t enough staff on weekends, and staff interviewed stated they did not. They stated “I wouldn’t work at a place that was short-staffed.” Staff stated they were not required to work double shifts. They further mentioned that when a staff called out sick, the Business Office Manager and Activities Director would assist with residents’ needs. Based on the information obtained, the allegation that, “The facility has an insufficient amount of staff to meet the residents’ needs.” is Unsubstantiated. Exit interview conducted, and a copy of the report emailed to administrator.