It was reported that resident fell several times due to staff not coming to assist them upon request. LPA reviewed schedule for October 2024. From 10/1/24 thru 10/22/24 the schedule list time of supervision and whom the resident is being supervised by. LPA also request copies of all fall Special Incident Reports(SIR) and LPA did not receive not one report for R-1 nor did LPA find any copies of SIRS received for R-1 in Community Care Licensing Division (CCLD) faxes received.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff providing appropriate supervision to avoid resident falls? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are staff providing sufficient supervision?” Of those interviewed, 6 out of 8 answered yes, 2 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility staff are not providing resident with appropriate supervision, resulting in falls,” therefore the allegation is unsubstantiated.

Allegation: Staff are mismanaging resident's medication

It was reported that R-9 did not receive medications on 9/24/24 and 9/25/24. On 10/22/24, LPA requested, received and reviewed copies of R-9’s electronic Medication Administration Record and upon review, LPA observed that all medications were administered per doctor’s instructions. The electronic MAR also has the initials of the tech and the times that the medications were administered.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, if staff were mismanaging the resident’s medications? Of those interviewed, 8 out of 9 answered no, and 1 said they didn’t know. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff mismanaging your medications?” Of those interviewed, 6 out of 8 answered no, 1 answered yes and 1 does not receive medication at this time. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are mismanaging resident’s medication,” therefore the allegation is unsubstantiated.

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It was reported that a R-1 needed assistance with their incontinence needs and staff were not available during the period of time when they are known to be incontinent. LPA interviewed R-9 about the allegation and she stated that she is sometimes assisted with incontinence issues but staff could be better and more consistent with the assistance that they provide to the residents.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff ensuring that resident’s toileting needs being met? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are your toileting needs being met?” Of those interviewed, 5 out of 8 answered yes, and 3 had answers other than yes and no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that resident’s toileting needs are being met,” therefore the allegation is unsubstantiated.

Allegation: Staff do not ensure that resident's showering needs are being met.

It is being reported that staff are not assisting R-1 with their showering needs as there are lack of towels. During interview with S-1, LPA learned that both washing machines were broken and staff were making runs to the laundry mat to wash items for residents in care. LPA reviewed the invoice dated 10/10/24 in which a representative from Glen Park purchased two washers and two dryers.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff ensuring that resident’s showering needs being met? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are your showering needs being met?” Of those interviewed, 7 out of 8 answered yes, 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that resident’s showering needs are being met,” therefore the allegation is unsubstantiated.

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On 10/22/24, LPA spoke to Executive Director, Michael Mendoza regarding the allegation regarding facility’s inability to provide clean linen for the residents. Mr. Mendoza stated that the facility’s laundry room was down as the washing machines were broken. Mr. Mendoza also stated that he had recently purchased two washing machines. LPA reviewed the invoice dated 10/10/24 in which a representative from Glen Park purchased two washers and two dryers. At the time when washing machines were down, staff were doing laundry runs to the neighborhood laundry mat to provide clean linen to residents in care.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff ensure that facility has sufficient clean linen? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, do you receive clean linen?” Of those interviewed, 8 out of 8 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that facility has sufficient clean linen,” therefore the allegation is unsubstantiated.

Allegation: Facility is serving expired beverages

On 10/22/24, LPA Shirley toured the facility’s kitchen, LPA inspected all cabinets and refrigerators. During the inspection, LPA observed that there were no expired beverages in the refrigerator. LPA spoke with S-6 and was told that kitchen staff follows the first rule of food storage, first in first out. The milk carton with the earliest use-by date should be stored in front and used first. This system ensures that older stock is used before newer stock, reducing the risk of spoilage and waste.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff serve expired beverages? Of those interviewed, 9 out of 9 answered no. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff serve expired beverages?” Of those interviewed, 6 out of 8 answered no, 1 answered yes and 1 did not know. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility is serving expired beverages,” therefore the allegation is unsubstantiated.

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It is being reported that R-9 is not allowed to eat when they return from outings. LPA reviewed the facility’s House Rules, and they state that residents have access to food and drink at any time and may request a snack from a staff person. House Rules also states that residents will be reminded of the options to have food and drink at any time requested. During interviews, S-1 stated that there is Juice during snacks, there are 3 snacks and 3 meals. S-1 and S-6 stated that the kitchen staff makes extra sandwiches. S-4 and S-9 stated that seconds are allowed.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff ensure that residents receive a sufficient amount of food? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, do you receive a sufficient amount of food?” Of those interviewed, 7 out of 8 answered yes, and 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents receive a sufficient quantity of food,” therefore the allegation is unsubstantiated.

Allegation: Staff do not ensure that facility is kept clean and sanitary

On 10/31/24 at 9:47am, LPA Shirley noted that there was a fresh smell upon entering the facility. LPA Shirley arrived to this facility and observed a team of staff cleaning in the lobby. LPA Shirley observed this facility’s housekeeping schedule and learned that the facility is cleaned on a daily basis and cleaning detail is assigned to cleaning staff according to zones.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff make sure that the facility is kept clean and sanitary? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff make sure that the facility is kept clean and sanitary?” Of those interviewed, 7 out of 8 answered yes, and 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that facility is kept clean and sanitary,” therefore the allegation is unsubstantiated.

LPA Shirley conducted an exit interview, and a copy of this report was left for Interim Administrator, Melissa Flores.