complaint·October 16, 2024

On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 7 Out of 8 staff (S1-S2, S4-S8) interviewed stated facility staff enters resident bedrooms at least two times per shift. 6 Out of 7 staff (S1-S2, S4-S8) stated if a resident’s room is observed as not clean, staff will clean the bedroom. 5 Out of 8 staff stated the residents’ bedrooms are cleaned daily and house keeping cleans weekly. On September 20, 2023, August 7, September 10 and September 16, 2024, the Department conducted unannounced visits to the facility. LPA Monter observed the following bedrooms: as clean and sanitary (5,9,20,21,24,25,29,30, CE25, CE24, CE1, CE5, CE9, CE4). LPA Monter did not observe any resident bedroom as dirty or unsanitary. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff do not assist resident with grooming On March 16, 2023, the Department received a complaint alleging Staff do not assist resident with grooming. On August 7, 2024, LPA interviewed residents R2-R6. 2 Out of 5 residents (R2-R3) interviewed stated, they do their own grooming, but staff will assist if asked. Resident R4 stated he/she receives assistance with Grooming. 3 Out of 6 residents interviewed (R2-R4) stated they have not seen other residents dirty or in a disheveled state. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed. On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 7 Out of 8 staff (S1-S2, S4-S8) stated if a resident is seen dirty or in a disheveled state, staff will immediately help clean them up. 8 Out of 8 staff interviewed stated staff helps residents with their daily grooming. 8 Out of 8 staff stated they have not seen a resident in a disheveled state. Page 2 Out of 3. On September 20, 2023, August 7, September 10 and September 16, 2024, the Department conducted unannounced visits to the facility. LPA Monter did not observe any residents who were not groomed or in a disheveled state. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff locks resident inside of resident's living unit On March 16, 2023, the Department received a complaint alleging Staff locks resident inside of resident's living unit. On August 7, 2024, LPA interviewed residents R2-R6. 3 Out of 5 residents (R2-R4) stated staff don’t lock residents inside their rooms. 3 Out of 5 (R2-R4) residents interviewed stated they can unlock their bedroom door by twisting the doorknob. Resident R5 was unable to provide LPA answer and would digress to unrelated topics. Resident R6 declined to be interviewed. On August 7, and September 10, 2024, LPA interviewed staff S1-S8. 8 Out of 8 staff interviewed stated staff don’t lock residents inside their bedrooms. 8 Out of 8 staff interviewed stated residents can twist the doorknob and the door can open. On September 20, 2023, LPA Monter toured the Memory care unit. LPA observed resident bedroom doorknobs can unlock from the inside by twisting the doorknob. LPA did not observe any other locking mechanism on the door besides the doorknob. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 3 Out of 3. Based on a Review of R1’s Physicians Report, dated July 19, 2022, resident R1 does not have bowel or bladder impairment. Furthermore, the report states R1 is able to care for his/her own toileting needs. The Department reviewed R1’s Resident Functional needs Assessment, dated October 18, 2022. The assessment states R1 requires limited assistance, wherein the facility would escort R1 to the bathroom 6 times per day. Based on a review of Facility Progress Notes, dated October 5, 2022, stated R1 is now incontinent. The Note states the facility implemented 3-hour toileting but R1 would be placed on the toilet but R1 would did not have a bowel/bladder movement. The note stated R1 would then use the restroom on the floor 10 minutes later. The Department was unable to interview Resident R1, who no longer lives at the facility. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff do not monitor resident for change in condition On March 16, 2023, the Department received a complaint alleging Staff do not monitor resident for change in condition. Its been alleged that the facility staff did not know R1 had a Urinary Tract Infection (UTI). On December 22, 2022, LPA Marrufo interviewed Witness (W1). W1 stated he/she was informed by the facility regarding the UTI. W1 stated, the director told him/her a care giver had observed blood in R1’s urine. On August 7, 2024, LPA interviewed staff S1-S6. 4 Out of 6 staff interviewed (S1, S2, S4, S5) stated when shifts change, the leaving shift informs the upcoming shift of any changes of conditions they observed during their shift. 5 Out of 6 staff interviewed stated when they observe a change of condition, they will inform the medtech/Memory care director. Staff S1-S3 stated they remember R1 but do not remember working with him/her. S4-S6 stated they are new employees and had no interactions with R1. Page 2 Out of 3. Based on record review, there is no incident report regarding R1 having a UTI. Based on a review of R1’s Resident Diagnosis Management form, dated September 23, 2024, the form does not indicate that R1 had a diagnosis of a UTI, during his/her stay at the facility. According to Mayo Clinic ( https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447 ), UTIs don't always cause symptoms. When they do, they may include: … Urine that appears red, bright pink or cola-colored — signs of blood in the urine . The Department was unable to interview Resident R1, who no longer lives at the facility. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 3. END OF REPORT.