complaint·October 4, 2024

Allegation: “Staff do not properly maintain the kitchen area:” The reporting party indicated that during a recent visit at the facility, the kitchen area was observed to have sticky floors and the refrigerator handle had food particles on it. The visit occurred beginning around 05:00PM and the facility staff told the reporting party that they were in the middle of cleaning, as the residents finished dinner. During the initial complaint visit, LPA observed the kitchen to be clean and without any noticeable food residue observed in the kitchen. The LPA noted staff present in the kitchen cooking upon arrival to the facility, however, the kitchen was clean. Staff interviewed stated that there is a resident who comes into the open kitchen often, but that resident is redirected. During the subsequent complaint visit, as LPA approached the front door, LPA observed staff cleaning up the kitchen area following lunchtime. The kitchen was observed to be clean and hazard free. Staff interviewed indicated that after the residents’ needs are met after meals, they clean up the kitchen area, as well as cleaning up while cooking and preparing meals. Based on observation and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not properly maintain the kitchen area” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not providing adequate supervision to the residents:” The reporting party indicated that the hallway door was closed during their recent visit at the facility and when the reporting party asked the staff how they would be able to hear the residents residing in those rooms, the caregiver did not provide an adequate response. LPA observed during the initial complaint visit that the door the reporting party was concerned with is a fire door, as thus, the door is required to remain closed at all times for the safety of the residents. Upon arrival at the initial visit, LPA observed the door to be propped open. LPA issued a citation related to fire clearance as a part of the concurrent annual visit. Staff then closed the door and it remained closed for the duration of the visit. LPA observed staff walking about the facility and opening the door to check on residents throughout the visit. Residents interviewed felt their needs were met, staff are accessible when needed and that there is adequate supervision. LPA did not note any concerns related to supervision on either the initial or subsequent complaint visits. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not providing adequate supervision to the residents” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.3) Allegation: “Resident is locked inside their bedroom:” The complaint alleges that the door to Resident #1 (R1)’s bedroom has a lock which does not have a key and that the resident is locked inside their room to prevent wandering behavior. LPA interviewed staff and R1. Staff did indicate that R1 has wandering behavior and that R1’s door does have a lock on their door for privacy. Staff interviewed stated R1 locks the door, not the staff and that R1 is able to enter and exit their private room without assistance. During the initial complaint visit, LPA spoke with R1 who confirmed they have a lock on their door. LPA observed R1 inside their room. R1 was able to both engage and disengage the lock, as they desire, and R1 was able to exit their room without assistance. Based on interview and observation, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “resident is locked inside their bedroom” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are unable to communicate effectively:” The reporting party indicated there is a language barrier between the staff and the reporting party and that staff did not understand what the reporting party was trying to convey. LPA Dulek spoke with staff both informally and formally during both the initial complaint visit and the subsequent complaint visit. Another LPA also recently conducted an unrelated visit. Neither LPA noted concerns related to communicating with the staff. Residents interviewed indicated that the staff understand and are able to communicate with residents with basic English. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are unable to communicate effectively” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility is not maintained in a clean and safe condition:” The complaint alleges that there is water dripping from a vent located in the front entry leading to the kitchen area, which is causing a slip and fall hazard in the facility. During the initial visit, LPA did not observe any water leaking. At the subsequent complaint visit, LPA did note some condensation on the vent, however there were no drips and no water on the ground underneath the vent during either visit. LPA advised the Facility Designee to be aware of the vent gathering condensation. LPA did note that both the initial complaint visit and the subsequent complaint visit were conducted at times when the weather was very warm outside and the air conditioning was running frequently. During the visit, Facility Designee informed the Administrator Report Continued on LIC 9099-C (p.4) of the potential for water dripping from the vent and maintenance will be out to assess the vent. Facility was observed to be clean and no immediate health and safety hazards were observed during either complaint visit. Residents interviewed indicated they have not observed any safety hazards and the facility is cleaned sufficiently to meet their needs. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility is not maintained in a clean and safe condition” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not providing adequate food service to a resident:” LPA observed food served and food present in the facility during both the initial and subsequent complaint visits. There was sufficient amount of food present to meet the minimum 2 days perishable and 7 days non perishable in all food groups during both visits. LPA observed soup and sandwiches served during lunch time. Residents interviewed indicated that food is varied and they are happy with the food served at the facility. Snacks are available as well as regular meals. Staff stated that meals consist of proteins, vegetables, fruit and milk is offered to the residents also. Based on observation and interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not providing adequate food service to a resident” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not meet resident's incontinence needs:” The complaint alleges that incontinence odors were present upon a visit to the facility. The reporting party instructed the staff to check and change a resident’s incontinence brief, which staff completed, but indicated the resident was dry. However, the reporting party indicated the odor persisted. During both the initial and subsequent complaint visit, LPA did not encounter any evidence of incontinence odors. Residents interviewed indicated they are changed at least 3 times a day, if not more as needed. Residents stated their incontinence needs are met. Staff interviewed indicated they check the residents every 1-2 hours and that residents are changed whenever they are observed to be wet during their checks. Residents are showered at least twice a week, if not more as needed based on each resident’s incontinence needs. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff do not meet resident’s incontinence needs” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with Facility Designee. A copy of today’s report was provided.