Complaint Investigation Report

Allegation: Facility did not provide adequate incontinent care. It is alleged residents are left to sit in their soil undergarments. To investigate this allegation, LPA Rios reviewed Complaint Control #31-AS-20200131112457 with the allegation; facility failed to provide proper incontinence care. On 02/27/2024 LPAs Angela Panushkina and Huma Rahimi conducted interviews with six (6) residents and based on four (4) resident interviews the allegation was deemed substantiated at the time. Due to the both allegations involving incontinent care this allegation is deemed Substantiated. The facility has submitted a plan of correction that was received and cleared by LPA Panushkina on 03/04/2024 no citation will be issued on today’s visit.

Allegation: Staff are mishandling the residents medications. To investigate the allegation LPA reviewed an incident report submitted to Community Care Licensing (CCL) for an incident that occurred on 03/04/2024. Mentioned on the incident report was that resident #2 (R2) was given another resident's medication. According to the report staff #1 (S1) was preparing medication for R2 when they were called away to provide assistance. When S1 retuned they continued to pass medication to R2. S1 shortly after realized they had provided the wrong medication to R2. LPA's interview with staff Jesse Wong revealed S1 received a re training from him that included reviewing previous medication training. LPA's review of S1 records revealed they received their initial medication training on 12/29/2021 and an annual training on 02/21/2022. Based on the information reviewed this allegation is deemed Substantiated at this time.

Allegation: Staff did not address the flooding issues on the facility grounds. It is alleged a room in the memory care unit had a flood and the facility has not dealt with it. To investigate the allegation LPA Rios conducted a tour of room #2 at approximately 2:50 p.m. in the designated memory care unit and observed the carpet still had extensive water damage. LPA observed some carpet pulled up from the entrance of the room and fans in the room used to dry flooring. LPA smelled a musty odor in the room. Interview with staff #2 (S2) revealed the room had a flood that originated from it's bathroom and the facility is working on remodeling the room. Room is currently vacant and is kept locked. Based on observations this allegation is deemed Substantiated at this time.