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.

In regards to allegation: Staff did not ensure that the resident's incontinence care needs were properly met at the facility. It is alleged that several residents had double diapers, including Resident 1 (R1), who was not kept clean. LPA's interviews revealed the following: The Administrator stated that there are (5) caregivers assigned to am and pm shifts and 2 or more caregivers during night shift but if there is a staff shortage, staff from other shifts or agency staff are called in for assistance. (7) caregivers and (1) witness stated they are assigned to 12-16 residents per shift, of whom only 7-8 residents need total assistance with ADLs and approximately 7-8 residents are independent and capable of managing their own ADLs. All (7) staff stated they ensure residents are usually clean and dry, when they start their shifts. They check on residents with incontinence needs every hour, sometimes residents are taken to the bathroom or sometimes changed in bed. Sometimes residents have accidents in bed, even several times a day and they are always cleaned, changed and clothing or bed sheets are changed. All (7) staff and (1) witness stated they make sure residents’ incontinence clothing are always clean and dry and they never put on double diapers. LPA interviews with residents revealed the following: R1 stated staff always check on R1 and make sure pull ups are clean, otherwise they clean R1 and pull up are changed and R1 is never double diapered.

Continued on 9099-C

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.

In regards to allegation: Staff did not keep the resident's room free of pests. It is alleged that there were roaches in one of rooms. LPA interviewed the Administrator and Maintenance Director, who stated that staff or residents notify them of any issues in resident rooms or common areas and a maintenance order is placed. Maintenance Director stated a professional pest control company comes to the facility, twice a month, once in the morning and one at night, for preventive measures. The pest control company is responsible for addressing any rodent or insect issues but there has been no issues since end of last year. The pest control company uses chemicals safe for humans. LPA interviewed (7) staff and (10) residents who stated they have not seen any infestations in rooms or common areas. LPA visited common areas, kitchen and multiple rooms in both floors and did not observe any insects or signs of infestation.

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.

In regards to allegation: Staff did not provide proper transfer assistance to residents in care. It is alleged that transfers for patients that cannot bear weight are done without any hoyer lifts, which is both risking the caregiver and the patient's safety. LPA's interviews revealed the following: The Administrator stated facility only has two residents that are heavy and require 2-3 staff assistance for transfer. All staff, including the agency staff are trained in transferring, lifting and repositioning residents and there are continuous training on resident care. Facility has a mechanical hoyer lift and transfer boards, which staff sometime use to transfer heavy or non-weight bearing residents but generally caregivers ask each other for assistance if needed. Interviews with (7) caregivers and (1) witness stated they are assigned to 7-8 residents in need of total assistance with ADLs and they are capable of transferring themselves to beds, showers and wheelchairs and don’t require 2-3 staff transferring assistance. All staff interviewed mentioned that they prefer to assist the residents themselves and generally do not use the hoyer lift but if they need help, they communicate with other caregivers to transfer residents. LPA Interviewed (10) residents, (5) residents stated that are independent. (5) residents mentioned generally they are able to transfer or reposition themselves but staff always assist them for safety purposes.

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.

Exit interview was conducted with and a copy of this report was provided to the Administrator.