Regarding allegation facility is not clean, safe, or sanitary. Per Reporting party, the facility has lead paint in west wing of facility, paint bubbles on R1’s bedroom ceiling and bathroom windowsill contain lead where staff put new rolls of toilet paper for residents to use. During the investigation, on 2/8/2024 and 2/27/2024 LPA/staff toured, made observations at the facility including all bedrooms and bathrooms used by residents in care. During the tour of the physical plant the bedrooms and bathrooms appeared clean, free of odors and sanitary. Based on LPA’s observations, the paint bubbles on R1’s bedroom ceiling and bathroom windowsill were in acceptable condition, no issues were observed. LPA conducted interviews with staff and residents on the same dates, they did not express any concerns about the physical plant of the facility. Based on LPA’s interviews and observations, LPA has determined and confirmed that although the bathrooms were clean and in a sanitary condition on recent LPA’s inspections conducted on 2/8/2024 and 2/27/2024, LPA is unable to determine if an area of the facility was unclean or unsanitary condition at a prior date. A finding that the complaint allegation occurred of facility is not clean, safe, or sanitary is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation about the facility staff is not ensuring residents have clean bed linens. The reporting party alleges for over a week staff had been asked to have bedding changed as it now smells of urine, but staff (S4) came in on 12/20/23 and swept under other’s resident bed and changed their bedding. However, R1’s bedding was never changed by any staff. Also, R2’s had three blankets that needed to be washed as well. Based on records review of facility daily care notes, on 12/11/23 it was brought to their attention that R1 demands to do their laundry at least twice per week. During the investigation, on 2/8/2024 and 2/27/2024, LPA conducted confidential interviews with four residents (R1, R2, R3 & R4) and four staff (S1, S2, S3 & S4) who told LPA that the facility has specific staffing (S1) to change beddings once per week or as needed. Based on LPA’s observations, on 2/8/2024 and 2/27/2024 LPA/staff toured the facility including three beds that were made and five of the residents were in their beds including R1 (R1, R2, R3, R4 & R5). LPA observed that one of the nine beds inspected was unmade but had been stripped of its linens and the housekeeper was in the process of making it up. S1 stated that the rooms are cleaned thoroughly once per week and if the room is not on the housekeeping schedule that day, other staff are able to make up the bed. Three out of four residents interviewed did not report any complaints about the housekeeping staff or cleanliness of the rooms.

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A finding that the complaint allegation occurred of facility staff is not ensuring residents have clean bed linens is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An allegation of personal rights was received by the Department. Per reporting party, there is another resident (unknown) who walks around the facility naked, and staff don’t do anything about it. Based on records review of facility daily care notes during the months of December 2023 and January 2024, there are no incidents reporting any resident walking around the facility naked. During the investigation, on 2/8/2024 and 2/27/2024, LPA made observations and conducted confidential interviews with four residents (R1, R2, R3 & R4) and four staff (S1, S2, S3 & S4). Based on their responses there were no concerns around this type of incident where any resident was observed walking around the facility naked, residents expressed that they feel safe in the facility. A finding that the complaint allegation personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of medications not being given per doctor's orders. It was alleged that a resident (R1) takes 10 medications, but they were only given 6. The Reporting party was unable to provide which dates this allegedly happened and what medications were missing. Based on LPA’s records review and observations made at the facility on 2/8/24, LPA performed a spot check of 5 out of 25 resident's (R1-R5) medications including R1's medications. LPA was not able to find any issues with resident’s medications. R1 was prescribed with tamsulosin HCL 0.4mg - 1 tab daily, metformin 1000mg - 1 tablet by mouth twice daily, gabapentin 100mg - 2 capsules by mouth three times daily, risperidone 2mg - 1 tablet by mouth twice daily, benztropine 0.5mg - 1 tablet by mouth twice daily, amlodipine 10mg - 1 tablet by mouth once daily, then the following medication were prescribed as needed acetaminophen 325mg – 2 tablets as needed every 8 hours for pain, ibuprofen 400mg – 1 tablet as needed for pain and calcium antacid 750mg – chew and swallow 1 to 2 tablets as needed for heartburn or diarrhea. Based on the Centrally Stored Medication and Destruction (CSMD) log, all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's physician as prescribed in R1’s physician report dated 8/27/2023. A finding that the complaint allegation medications not being given per doctor's orders is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.