This complaint alleged that facility front door is damaged.

LPA Calderon conducted an interview with A1. A1 states that a resident struck the front door to the facility with a wheelchair damaging the front door. A1 states that there was no safety issues and staff boarded up the door for safety issues. A1 states that staff and guests to use the front door damaged and A1 ordered a new door and glass. A1 states that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that the front door was damaged by a resident wheelchair and was not a safety issue for residents. 6 out of 6 staff state that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the front door has been damaged for 3 weeks and was not a safety issue. 9 out of 10 residents state that staff maintain the facility and the facility is not in disrepair. On 04/10/2024 LPA Calderon reviewed email from DBA Glass Land (date 03/14/2024). Emailed noted that staff was given a quote for $10,000 dollars to replace the front door. LPA Calderon reviewed quote from DBA Glass Land (date 04/10/2024) for glass replacement. LPA Calderon and A1 toured the facility. LPA Calderon noted that staff and vendor were working on the facility front door. LPA Calderon toured the facility common area, and the facility was not in disrepair. LPA Calderon inspected room 263, 292, 304,306, 315 and 316 and there were no issues with the residents’ rooms.

Allegation 2: Staff did not administer residents’ medication as prescribed.

This complaint alleged that staff did not advise resident about medications taken.

LPA Calderon conducted an interview with A1. A1 states that staff are trained to advise residents regarding the medications given. A1 states that staff must advise residents regarding medications given. LPA Calderon conducted an interview with staff (S1-S6). S3 and S5 (Med tecks) state that they always advise resident the name of the medications they are giving to the residents. S3 and S5 state that staff are given training on how to give medications to residents in care, LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the Med-tecks always advise them of the medications they are taking. 9 out of 10 residents state that they know the name of the medications they are taking and what the pills look like prior to taking the medications. Reviewed training from Relias Company and Regal specialty pharmacy regarding medication management medication review.

This complaint alleged that staff do not knock on resident room door prior to entering.

LPA Calderon conducted an interview with A1. A1 states that all staff are given training on how to enter a resident’s room. A1 states that staff are trained to knock 4 times and to advise the resident why they are coming inside the room. A1 states that R1 shares the room with another resident and may have been confused as to why the staff entered the room. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they always knock on resident’s front door prior to entering and 6 out of 6 staff state that staff always advise residents why they are entering the room. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that staff always knock on the front door prior to entering and 9 out of 10 residents state that staff always treat them with respect. LPA Calderon reviewed In-Service training (date 3/6/2024 and 03/13/2024). Training provided to all staff on being respectful and the proper way to enter a resident room. LPA Calderon toured the facility with Administrator and staff. Staff knocked on front doors to 263, 292, 304, 306, 315 and 316. Staff knocked and advised why they were entering the resident room.

Allegation 4: Staff do not assist residents in a timely manner.

This complaint alleged that staff do not answer call button when pressed by residents.

LPA Calderon conducted an interview with A1. A1 states that staff are given training on what to do if a resident pushes the call button for help. A1 states that staff do answer call buttons every day and on average it takes 5 to 10 minutes to answer the call. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they are given training on what to do if a resident pushes the call button for help. 6 out of 6 staff state that normally it takes staff 5 to 10 minutes to answer a resident call button for help. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that when they push the call button for help it takes staff 5 to 10 minutes to respond to their call for help. LPA Calderon reviewed In-service training (date 03/06/2024 and 03/13/2024) regarding how to respond to a resident call for help. LPA Calderon toured the facility with A1. LPA Calderon entered rooms 263, 292, 304, 306, 315 and 316. LPA Calderon pushed the room call button and average response from staff was 2 to 6 minutes.

This complaint alleged that staff do not speak to resident in English.

LPA Calderon conducted an interview with A1. A1 states that all A1 staff first language is not English. A1 states that all A1 staff can communicate in English and if not can find a staff member that can communicate with the residents. A1 states that if a staff member can not find a way to communicate with residents, they may not have a job. A1 states that it is normal for staff to speak to each other in a language other than English. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state they have no issues communicating in English and 6 out of 6 staff state that they have no issues speaking to residents in care. LPA Calderon noted 1 out of 6 staff that LPA Calderon spoke to the staff member in Spanish, but the staff did understand English and spoke some English. LPA Calderon conducted an interview with residents (R1-R10). 8 out of 10 resident state to have no communications issues with staff and can speak to staff in English.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility is in disrepair”. “Staff did not administer resident's medication as prescribed”. “Staff do not treat residents with respect”. “Staff do not assist residents in a timely manner”. “Staff cannot communicate effectively with residents due to language barrier” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Janie Acosta (A1).