On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Facility staff are not providing resident medication when needed. S1 stated that all of prescribed medications are given according to the doctor’s prescription and given on the specific days and times indicated. Additionally, S1 stated that at no time have they not adhered to those orders. LPA observed the medication for all residents and did not observe anything unusual in the dosage or delivery of such medication.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility staff are not providing resident medication when needed. S2 denied the allegation and asserted that they are following what the doctor has prescribed for each of the residents. And that all medications given with the dates and times are noted in the Medication Administration Record. LPA did not observe any discrepancies in the record.

On 05/10/23, LPA interviewed R1-R6 about the allegation that Facility staff are not providing resident medication when needed. Residents R1-R2 denied the allegation. R3-R6 was not able to be interviewed due to cognitive impairment issues. LPA reviewed the records and did not observe any discrepancies in the record.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Facility staff are not providing resident medication when needed. 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 allegations are Unsubstantiated.

The investigation revealed the following: Regarding allegation #2: Facility staff are not following resident's care plan.

On 05/10/23, LPA interviewed S1. S1 denied the allegation that Facility staff are not following resident's care plan. S1 stated that the facility is following the hospice care plan. The hospice caregivers come 3 times weekly to give care, diaper change, wound care, and refill all medications that are needed. Additionally, a nurse comes two other times throughout the week to bathe the resident. And the days that hospice does not come; the staff does the incontinence care, turning of the client, bathing, and any other items that need to be addressed by the facility.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility staff are not following resident's care plan. S2 denied the allegation and asserted that they are following the care plan that hospice has implemented and has not deviated from it. S2 stated that hospice comes a varied number of times throughout the week to take care of the resident and the facility provides care for those days that hospice is not available for the additional days of the week.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Facility staff are not following resident's care plan. Residents R1-R2 denied the allegation. LPA observed that the residents seem healthy, clean, and living in sanitary conditions. R3-R6 could not be interviewed due to their cognitive impairment issues. LPA observed that the residents seemed to be healthy, clean, nourished, and in good spirits.

Report continued on LIC9099-C

The investigation revealed the following: Regarding allegation #3: Facility staff do not provide resident care checks for extended periods of time.

On 05/10/23, LPA interviewed S1. S1 denied the allegation that the Facility staff do not provide resident care checks for extended periods of time. S1 stated that all care checks are done throughout the course of the day, and that there is someone at the facility 24 hours a day. In addition, the facility has a monitoring app that’s placed outside the room of each client to ensure compliance with monitoring of the resident. LPA observed the app that monitors the outside of the rooms of the residents and found it to be reliable.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility staff do not provide resident care checks for extended periods of time. S2 denied the allegation and stated that they are always monitoring the residents and their well-being while in the facility. Additionally, S2 stated that S2 checks on the residents every couple of hours and more if needed, depending on the resident and their needs.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Facility staff do not provide resident care checks for extended periods of time. Residents R1-R2 denied the allegation and confirmed that they are receiving care checks throughout the day. While R3-R6 could not be interviewed due to their cognitive impairment , LPA did observe that they seemed healthy, clean, and living in sanitary conditions.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: the Facility staff do not provide resident care checks for extended periods of time. 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 allegations are Unsubstantiated.

Report continued on LIC9099-C

On 05/10/23, LPA interviewed S1. S1 denied the allegation that the Facility staff leave resident in heavily soiled briefs. S1 stated that all residents are provided care checks 3 or 4 times a day, or as needed to determine if they need to be changed or have their incontinence issues attended to. S1, additionally stated that all residents are different and have different care needs throughout the day, and that certain residents are checked on more often that others given their specific care needs. But at no time are any of the residents left in heavily soiled briefs.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility staff leave resident in heavily soiled briefs. S2 denied the allegation and stated that they are always monitoring the residents and checking to see if they have soiled their briefs. And anytime they notice this they change the resident immediately and get them into dry undergarments or diapers. LPA observed the residents seemed to be clean, and no smell was noticed at the time of the investigation.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Facility staff leave resident in heavily soiled briefs. Residents R1-R2 denied the allegation and confirmed that they are changed when they need to be changed and that they are never left in soiled briefs for an extended period of time. R3-R6 could not be interviewed due to their cognitive impairment , but LPA did observe that they seemed healthy, clean, and living in sanitary conditions.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: the Facility staff leave resident in heavily soiled briefs. 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 allegations are Unsubstantiated.

No deficiencies were cited.

An exit interview has been conducted and a copy of the Complaint Report provided to Licensee, Rukayat Adamson.