It is being alleged that rooms in the memory care unit are in badly need of repair. The department interviewed the facility Administrator (A1), who denied the allegation, stating that cleaning is done daily and that there is a cleaning schedule for Housekeeping to follow. On 12/20/24, between 09:30 am-02:00 pm, LPAs interviewed 8 residents (R1- R8). 8 out of 8 interviewed stated that the rooms are cleaned regularly. LPAs interviewed two (2) staff (S1, S4), and 2 out of 2 staff stated that rooms are cleaned daily unless the residents request not to have housekeeping clean the room that day. On 12/20/24, LPA obtained a copy of the daily cleaning schedule with outlined cleaning duties for the assigned staff (dated 12/ 2024, 04/2025) that indicates each resident's rooms are cleaned daily.

Based on the interview and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated.

Allegation #2: Staff mishandled the president’s personal funds.

It is being alleged that staff did not keep P & I documentation's and signatures of the residents showing transfer for cash. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 denied having any issue with their P & I fund. They also stated that they do not have any issue with the facility handling their funds, and they have had no discrepancies with their P & I fund. On 12/20/24, between 1:00 pm to 2:00 pm, LPAs interviewed the Administrator (A1), who denied the allegation and stated that not all the residents’ funds are being handled by the facility as some of the residents handle their funds.

Allegation #3: Staff do not have proper documentation regarding the residents.

It being alleged that the facility doesn’t have proper documentation for the resident. On 12/20/24, between 09:30 am to 12:00 pm, (LPAs) Richard and Lee requested, obtained and review eight (8) residents (R1 - R8) services records which included the following: Admission Agreement LIC 604, Appraisal/Needs and Services Plan LIC 625, Physician's Report LIC 602A, Identification and Emergency Information LIC 601. LPAs found written records, including Unusual Incident/Injury Reports LIC 624 for each client.

Based on the information gathered, reviewed, and obtained, there is no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated.

It being alleged that the facility did not report altercations between residents. On 12/20/24, between 1:00 pm to 2:00 pm, LPA interviewed the Administrator (A1) who stated that the facility always reports any incidents that happened at the facility regardless is residents on residents or staff between residents. A1 also stated that all staff are required to complete incidents report when they occur and they are reviewed, then sent out. The LPAs' records reviewed of all the Incident reports (dated 10/09/24 to 11/06/2024) indicated that the facility reports all the incidents to the proper agency or the responsible party of all the residents.

Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated.

Allegation #5: Staff did not prevent the residents from engaging in an altercation.

It is being alleged that the staff did not prevent the resident from engaging in an altercation. On, 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed the eight (8) residents (R1- R8). 8 out of 8 stated that when the residents were fighting each other, the staff always tried to separate them by stepping between the residents. They also stated that the facility usually calls 911 if they don’t stop.

Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated.

Allegation #6: The Staff allows residents to be soiled for an extended period of time.

It is being alleged that the residents are often left soiled for hours. On 12/20/24, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 stated that they get changed every two hours. 1 out of 8 stated that the longest they waited to be changed was around 30 minutes or so after they pushed the button. The staff do their best. On 12/20/24, between 1:00 PM to 2:00 PM, LPAs interviewed the Administrator (A1), who stated that the facility has a changing schedule, which is typically every 2 hours and/or earlier as needed. LPAs interviewed staff (S4) who stated that the facility has a schedule to change the resident every two hours. But if the residents push the call button, the next available staff member will go and help the residents. On 12/20/24, records reviewed of the changing schedule (dated 12/01/24 -12/20/24) indicated the staff does change the residents every two hours and sooner if the residents are in need.

Allegation # #7 Staff did not address the resident's change in medical condition.

It is being alleged that staff did not have the right level of care plan for the resident, resulting in the resident going to the hospital multiple times. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 denied the allegation. LPAs interviewed 1 out of 8 residents who stated multiple visits to the hospital and stated it is to make sure the heart and body ache are not life threatening. Not because the facility does not have a care plan, the facility provided a great care plan during admission. LPAs interviewed two (2) staff members (S2- S3). 2 out of 2 denied the allegation and stated that MedTech pass meds, and are responsible for giving the medications. The Licensed Vocational Nurse (LVN) also monitors the condition of the resident if the resident's care plan needs to be reassessed. On 12/20/24, records reviewed of needs of services plan (dated 10/29/24) indicated that the facility is addressing the residents' change in condition every year.

Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated.

It is being alleged that staff did not give the resident medication of insulin in time. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed seven (7) residents (R1- R7). 7 out of 7 denied the allegation and stated that the facility staff provides services on time, and they are happy with the staff's response time. The facility is a big place, so it depends on the shift; some are busier than others, so it may take them time to get to you after you push the button. The staff do their best. LPA records review of Medication (dated 11/01/24 to 11/30/24) indicated that all clients received the correct medications on time. On 12/20/24, at 1:00 pm, LPAs interviewed two (2) staff members. All denied the allegation and stated that when a resident needs medical attention, we do provide the resident the help they need, especially if the resident is on insulin injections. The only time insulin is not given is when the instructions call for the insulin to be held if a reading is too low, and when that happens, it is documented on the MAR. Also, if the resident is in a hospital or refuses and that too is documented on the MAR.

Based on the interview and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Catherine Dacara