Complaint Investigation Report

This was documented by the facility on an LIC624 (Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Community Care Licensing. On 01/12/2023 LPA Jeffries interviewed Staff 1, and 2 (S1, S2) who both stated that they did not observe R13 to have any rash or soars on his body before 12/01/2022. Interviews on 01/12/2023 with S1-S6 stated that residents who are on COVID protocols during this time residents are checked and accessed by direct care staff a minimum of 6 times per day. On 01/12/2023, LPA interviewed R1-R12, all stated no issues with care, and no issues with facility. R13 was not available for interview. Based on documentation of Care evaluation in October, and LIC624’s in November of 2022, resident care protocols during COVID outbreak, and Resident and Staff interviews, there is not enough evidence to support the allegation of, “Resident sustained pressure injuries while in care.” and is unsubstantiated at this time.

As to the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility.” It was alleged that all of the fire extinguishers are overdue for their annual inspection/certification. It was discovered through observation, interviews and documentation that on 01/04/2023 and 01/12/2023, LPA Jeffries conducted a full facility walkthrough and observed more than 30 fire extinguishers throughout the entire facility all to be tagged and in working pressure range. LPA also observed and collected documentation of Inspection, Testing, and Maintenance of facilities integrated sprinkler system performed by Alpha Fire Unlimited on 08/23/2022. LPA Jeffries also collected documentation of last fire drills conducted on 12/28/2022 and 12/29/2022 to cover all three floors of the facility, which exceeds regulations standars. At this time there is not enough evidence to support the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility” and is unsubstantiated at this time.

As to the allegation of, “Resident are not provided proper food service.” It was alleged that Employees often do not wear their masks while serving meals and lack of staffing in the dining. It was discovered through interviews and observation that on 01/12/2024 LPA conducted interviews with R1-R12 all residents had no issues with food or food service, and staffing was also not an issue with Resident interviewed. On 01/04/2023 and 01/12/2023 LPA Jeffries made observations of staff who were all masked during respective visits. On 01/12/2023, LPA Jeffries interviewed S1-S6 stated that they have been following infection control policies and have been wearing appropriate Personal Protective Equipment (PPE) at all times while working. On 01/17/2023, LPA Jeffries collected and reviewed full facility schedule for December of 2022 and noted that call offs were noted but did not impact service in dining at the facility. At this time, there is not enough evidence to support the allegation of, “Residents are not provided proper food service.” and is unsubstantiated at this time. CONTINUED on LIC9099-C