• In regards to the allegation: “Staff does not ensure clients room is kept in clean, safe, sanitary conditions at all times.” It is alleged that the staff won’t come and empty the clients’ trash can in the room or sweep or mop the floors resulting in the client’s floors being dirty. Interviews conducted with the staff revealed that the housekeepers clean the clients’ rooms daily or as needed and do deep cleaning once or twice a week. All staff interviewed stated that trash is emptied, towels replaced and the clients’ basic hygiene supplies are replenished. Interviews conducted with the clients all indicated that the facility's maintenance is good and they are satisfied with the cleaning that is done by staff. 11 out of 12 clients interviewed stated that facility staff clean their bedroom and bathrooms once a day and do through/deep cleaning once or twice a week. During today's tour of the facility, LPA observed a housekeeper cleaning client bedroom (Room 205) and bathroom. LPA also reviewed documentation showing the housekeepers schedule and that the clients’ rooms assigned to them are cleaned on a daily basis. Therefore, there was insufficient evidence to corroborate this allegation.
• In regards to the allegation: “Staff does not ensure clients medications are properly managed.”It is alleged that staff in the medication room are mismanaging medications for clients. It is also alleged that R1’s PRN prescription have gone missing in the medication room and the staff stated that they didn’t know what happened to it. Interviews conducted with staff members denied the allegation. Interviewed staff stated that clients medications were never gone missing and they have not heard any clients complained about this. S5 stated that if a client has an order for a PRN, especially a controlled substance, they make sure it's double-locked in the medication room. S5 indicated that once the client ran out of their PRNs, the client has has to see a doctor and ask for refills. And for controlled substances, it is a protocol that the doctor will not refill until they’ve seen the client. Additionally, staff interviewed stated that they follow the specified dose instructed by the client's doctor and will not administer medication based on the client's request. Interviewed staff also indicated that they ensure they are passing out the correct medication to the clients by double checking the medication and verifying the clients name before passing out the medication. S1 stated that there are cameras in the medication room which are monitored closely. S1 indicated that he has not heard of this issue and no one has brought this to his attention. Interviewed clients stated that they receive their medication timely nor the facility staff have lost their medication. Clients interviewed also stated that the facility staff do a good job in administering medication Some clients stated that if they are out of refills, they call the doctor and they prescribe it. During today's tour of the medication room, LPA observed staff passing out medication to clients and the clients medications are secured and inaccessible to clients. LPA also reviewed the Medication Administration Records (MARs) for (5) random clients and did not observe any discrepancies. Therefore, there was insufficient evidence to corroborate this allegation.

Exit interview held and a copy of this report was provided to Andrew De Vera, Administrator.

Based on LPAs' observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.