The Department requested and reviewed the facility’s policy for scheduling staff in CPR and first aid. The policy indicated, the schedule for direct care staff will include at least one staff member who is trained in CPR and first aid on each shift. The person responsible for developing and maintaining the schedule will keep a list of all staff members who have a current CPR and first aid card. When the schedule is produced, the person responsible for developing the schedule will check that at least one person scheduled for each shift in the community has a current CPR and First Aid card. One person certified in CPR and First Aid working in either Assisted Living or Traditions will be sufficient for this purpose. If an unexpected absence results in no trained staff member being in the community for the shift, and if attempts to obtain a trained staff member to substitute are unsuccessful, the problem will be referred to the Executive Director for resolution which may necessitate that a management team member who has CPE and First Aid certification cover as the trained staff member for the shift. The Department requested and reviewed a total of ten (10) facility staff CPR and First Aid certifications. The facility has two CPR training sessions scheduled for February and March of 2024.

The Department interviewed and received statements from a total of seven (7) facility staff. Interview statement received from staff (S3) stated, Med Techs are required to be CPR certified to work at the facility. There is always one person who works in the community that is CPR certified either a Med Tech or staff. S3 stated the Department’s manager does the scheduling and they are aware who is CPR certified and would schedule them to work. Interview statement received from staff (S5) stated, was recently hired at the facility and is CPR certified. There is always a Med Tech on duty for each shift. If there is no Med Tech working at the facility due to call out or vacation the facility will find a replacement. If the facility is having a difficult time finding a replacement, then the Resident Care Coordinator will take over the position.

Per Health and Safety Code, while CPR training is not required for all direct care staff, licensees must ensure there is at least one staff person who has CPR training to be on duty and on the premises of a facility at all times.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without reasonable basis.

No deficiencies are being cited during today’s visit.

Exit interview conducted.

According to the interview statement received, there are cockroaches in the Memory Care Unit. There are rats running around the main entrance of the facility. A resident (R3) has lice and may have given other residents in care lice.

The Department interviewed and received statements from a total of five (5) facility staff and one (1) residents in care. According to staff (S2), it was verified that R3 did have lice. R3 started lice treatment after staff discovered it. R3’s responsible party and primary care physician was notified. Interview statement received from staff (S1) indicated, all residents in the Traditions Memory Care Unit were checked by the Health Services Director to ensure lice was not spread to other residents in care. R3’s belongings were washed. Interview statement received from staff (S5) stated, observed dead cockroaches, two rats, and a baby snack at the facility on different occasions. Management was notified. There was a total of three (3) facility staff who observed the rats in the lobby. Interview statement received from resident indicated did not observe any pests at the facility.

On 2/14/2024, LPA Keosavang arrived at the facility unannounced to commence complaint investigation. LPA toured the Memory Care unit and kitchen with staff (S1). LPA toured a total of five (5) residents’ bedrooms and bathrooms. LPA observed residents’ bedrooms and bathrooms to be clean, sanitary, and in good condition. All five (5) residents’ bedrooms and bathrooms were free of pests.

Allegation: Staff do not change residents timely. – Unsubstantiated.

According to an interview statement received, staff are letting residents in care sit in urine and feces resulting in bed sores. The Department requested three (3) resident’s physician’s report, admission agreement, assessments for review. According to resident’s (R3) physician's report, R3 is diagnosed with mild cognitive impairment. R3 cannot independently transfer to and from bed. R3 does not have a history of skin condition or breakdown. According to R3’s assessment, R3 requires complete assistance with toileting needs and has difficulty maintaining socially acceptable hygiene standards. R3 has fragile skin and needs skin checks up to 3 times a day. R3 has no healing wounds or bedsores. R3 requires checks 7-8 times each shift due to recent hospitalization, illness, medication change, etc. R3 requires services from hospice staff. Coordination of care provided by community nurse.

The Department received interview statements from a total of five (5) facility staff and one (1) residents in care. Interview statement received from staff (S3) indicated that R3 is in hospice and is bed bound. R3 requires staff to reposition R3 and the pillow that is being used. Interview statement received from staff (S5) indicated that R3’s room is located the opposite side of the memory care’s common area and tends to be “forgotten”. S5 stated R3 has bed sores, and the hospice nurse changes the dressing on the bed sores. Staff are required to assist R3 with repositioning and shifting pillows between R2’s legs every hour. S5 had observed R3 left in soiled brief on the AM shift. S5 stated on 2-3 occasions the staff had to change R2’s bedding due to it being soaked through.

According to interview statements received, the managers and kitchen staff were observed stepping outside by the employee parking lot to smoke marijuana before returning to work.

The Department interviewed a total of five (5) facility staff and one (1) residents in care. Interview statement received from staff (S1) indicated that there is a designated area for staff to smoke cigarettes and vapes. Interview statement received from staff (S3) indicated that there are staff that smoke and vape but have never observed staff smoking or vaping in the community. S3 denied smoking in the community. Interview statement received from staff (S5) stated, “There are a couple of staff that smokes marijuana and comes back smelling like it.” S5 stated, had not observed the managers smoking marijuana. Interview statement received from resident indicated did not observe any staff smoking marijuana at the facility.

Based on interview statements received, records review, and observations, the Department finds the above allegations to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report provided.