complaint·March 8, 2025

Allegation: Staff not providing adequate supervision to resident's. It was alleged that staff are not providing adequate supervision to residents. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was denied by 5 out 5 staff members that they do not provide adequate supervision to the residents. 5 out 5 staff members state that they able to meet the residents needs with the current staffing that they have. An interview with 8 residents were conducted. 8 out 8 residents state that they believe that they have sufficient supervision and report no issues. A review of the facilities staffing schedule was conducted. However, it was unable to use due to the time difference between the allegation and complaint finding. Based on the information gathered, it is unclear if the staff are not providing adequate supervision to residents. Allegation: Resident developed sores while in care. It was alleged that at resident developed sores while in care. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that R1 would state that they developed sores however when staff would access this resident there was no sores or indication that showed that the resident was developing a sore. In addition, LPA reviewed R1’s daily notes which showed that the staff would often do skin checks but did not find anything concerning any skin integrity issues. Based on the information gathered, it is unclear if the resident developed sores while in care. Allegation: Staff not providing resident with drinking water. It was alleged that staff do not provide residents with drinking water. During the course of this investigation LPA conducted interviews and toured the facility. An interview with 8 residents were conducted. 8 out 8 residents state that they do have access to water. 8 out 8 residents state that they did have individual water bottles, however, the facility has changed to having water that is brought by the staff members to fill out their pitchers. An interview with 6 staff members were conducted. 5 out 5 staff members state that they have implemented a new system where the facility has hydration carts on each floor that includes excess water pitchers and cups. These hydration carts are monitored by staff and are used to fill the residents personal pitcher in their rooms. 5 out 5 staff members deny that they do not provide residents with water. LPA conducted a tour of the facility, where it was observed that the facility does have 3 separate hydration carts available for residents and staff to use throughout the day. Based on the information gathered, it is unclear if the staff do not provide residents with drinking water. Allegation: Staff not responding to resident's emergency cord It was alleged that the staff are not responding to the resident’s emergency cord. During the course of this investigation, LPA conducted interviews and reviewed facility records. An interview with 5 staff members were conducted. 5 out 5 staff members deny not responding to a resident’s emergency cord. 5 out 5 staff members state that they try to get to the resident within 20 minutes. An interview with 8 residents were conducted 8 out of 8 residents state that they do not have any issues in obtaining any help when pulling their emergency cord. Based on the information gathered, it is unclear if the staff are not responding to the resident’s emergency cord. Allegation: Resident is required to dispose of trash. It was alleged that the residents are required to dispose of trash. During the course of this investigation, LPA conducted interviews with staff and residents. Based on interviews conducted it was denied by 5 staff members and 8 residents that the residents had to dispose of their own trash. Based on the information gathered, it is unclear that the resident required to dispose of trash. Allegation: Resident is required to clean facility commode It was alleged that the resident is required to clean the facility commode. During the course of this investigation, LPA conducted interviews with staff and residents. Based on interviews conducted it was denied by 5 staff and 8 residents that the resident is required to clean facility commode. Based on the information gathered, it is unclear that the resident required to dispose of trash. Allegation: Resident is required to purchase food. It was alleged that the resident is required to purchase food. During the course of this investigation, LPA conducted interviews and reviewed facility food supply. Based on interviews conducted, it was denied by 5 staff members and 8 residents that the facility requires the resident the purchase food. It was stated by 5 staff members that the residents are able to bring in any type of snacks that the facility does not have. In addition, a review of the facilities food supply was conducted which displayed a sufficient amount of food supply to meet the resident’s needs. A review of the facilities food receipts were also conducted. Based on the information gathered, it is unclear if the resident is required to purchase food. Allegation: Facility does not provide supplies for resident. It was alleged that the facility does not provide supplies for the resident. During the course of this investigation, LPA conducted interviews. It was denied by 5 staff and 8 residents that the facility does not provide supplies for the resident. Based on the information gathered, it is unclear if the facility does not provide supplies for resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility. Allegation: Facility has insects. It was alleged that the facility has insects. During the course of this investigation, LPA conducted interviews, reviewed facility records and toured the facility. Based on interviews conducted 5 staff and 8 residents deny that the facility has insects. Based on observation and records reviewed, it was learned that A pest control service agreement was reviewed and confirmed that on-going pest control service in place for facility. Based on the information gathered, it is unclear if the facility has insects. Allegation: Facility is unsanitary and staff do not clean facility. During the course of the investigation, LPA Pascua conducted site visits and inspected the facility. No unsanitary conditions were observed. LPA Pascua also interviewed 8 residents and 5 staff members, all of whom felt the facility is maintained in a sanitary condition and cleans on a daily basis. Based on the information gathered, it is unclear if the facility is unsanitary. Allegation: Resident is washing laundry in a sink and Facility washing machine is in disrepair. It was alleged that the resident is washing laundry in the sink. During the course of this investigation, LPA conducted interviews. Interviews conducted with 5 staff members and 8 residents denied that the resident is washing laundry in the sink and that the washing machine has been working. 5 staff members state that if one washing machine was not working, they have others that they could use. Based on the information gathered, it is unclear if the resident is washing laundry in the sink due to the facility washing machine being in disrepair. Allegation: Resident's bedding is dirty. It was alleged that the resident’s bedding is dirty. During the course of the investigation, LPA conducted interviews, and observed bedding conditions. Based on interviews conducted with 5 staff members and 8 residents it was denied that their bedding was dirty. LPA observed 8 resident beddings which did not have odor or any indication to show that the bedding was dirty. Based on the information gathered, it is unclear if the resident’s bedding is dirty. Allegation: Staff not following physician's orders. It was alleged that staff are not following physicians orders. During the course of this investigation, LPA conducted interviews in which it was denied by 5 staff members that they are not following physicians orders. An interview with 8 residents were conducted. 8 out 8 residents state that the facility does a good job in ensuring that any changes are communicated and done. Based on information gathered, it is unclear if the staff are not following physicians orders. Allegation: Resident left in a soiled diaper for a long period of time. It was alleged that the resident was left in a soiled diaper for a long period of time. During the course of this investigation, LPA conducted interviews which revealed that 5 out 5 staff members deny that they leave the resident’s in a soiled diaper for a long period of time. It was stated by all 5 staff members that they are required to change diapers as soon as they are soiled. An interview with 8 residents were conducted, who denied that they’re needs are not being met at this time. Based on the information gathered, it is unclear if the residents are left in a soiled diaper for a long time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.