JMJ Guest Home

Allegation investigated: Staff member physically abused resident while in care Resident sustained a fall while in care Staff failed to meet resident's needs

On 6/14/2023 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Lucia Dela Rea. The investigation consisted of the following: On 6/12/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested documents. LPA Spaeth requested the following documents: 1) staff and resident roster, and 2) R5’s physician report. All documents were received at the time of visit. LPA Spaeth interviewed R2, R3, and R5. R1 and R4 were unable to answer LPA’s questions. The investigation revealed the following Regarding the allegation, staff member physically abused resident while in care, it is alleged a caregiver had physically abused resident in care by punching and slapping the resident on 5/10/2023t. LPA interviewed R2 and R3 who stated staff has never slapped or punched them. R5 stated S1 and Administrator has never Unsubstantiated slapped or punched them. R5 stated a caregiver from a private resident had slapped and punched them on May 10, 2023. R5 lived at the private resident before moving to JMJ Guest Home. R5 stated moved into facility on May 22, 2023. . LPA interviewed caregiver and Administrator who both stated has never slapped or punched a resident. Regarding the allegation, resident sustained a fall while in care, it is alleged that resident sustained injuries due to a fall. R2, R3, and R5 stated have not fallen during the month of May, 2023 and June, 2023. The Caregiver and the Administrator stated residents have not fallen in the past two months. Regarding, staff failed to meet resident’s needs, it is alleged that resident fell due to the neglect of caregivers. R2, R3, and R5 stated staff has met resident’s needs. The Caregiver and Administrator both stated have met residents' needs. Administrator stated residents have not complained about the care they have received. Based on LPA’s interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jun 14, 2023 · control 31-AS-20230605090134

Type of visit: Required - 1 Year

LPA Spaeth conducted an unannounced annual visit to the facility at 1:45 pm. Upon approaching the facility, LPA observed the COVID signs on the door. LPA was greeted by caregiver who was wearing a mask and LPA stated the purpose of the visit. Caregiver confirmed there are four residents within the facility. LPA's temperature was taken and LPA answered the COVID questions at the sign in station. LPA observed thermometer, hand sanitizer and sign in sheet at the sign in station. The Administrator arrived at 2:10 pm. LPA and Administrator began tour at 2:10 pm. LPA Spaeth observed a resident in the living room watching television. LPA observed the living room contained comfortable seating. The dining room contained dining room table and dining chairs. The kitchen was clean. LPA observed the refrigerator was stocked with a two-day supply of fresh fruits and vegetables. The pantry was stocked with a seven-day supply of canned good items. LPA observed the knives were locked in a drawer and the cleaning supplies were locked underneath the sink. The kitchen sink area contained wash your hands sign, hand soap, and a trash can. The medications were locked in the kitchen. LPA observed the resident's bedrooms contained bed, linens, lamp, night stand, and chest of drawers. All rooms were neat and clean. LPA also observed two residents taking a nap in the resident's room. LPAs observed the two bathrooms contained the required wash your hands sign, hand soap, paper towels, and trash cans in each bathroom. LPA was then escorted to the garage and LPA observed a refrigerator which contained fresh vegetables, frozen meats and vegetables, canned goods, PPE supplies such as face shields, surgical gowns, and gloves. The backyard contained a shaded area with comfortable seating. The side gate that leads from the backyard to the front yard was not locked. There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 6, 2022

Type of visit: Required - 1 Year

LPA Melissa Spaeth, LPA Eleza Jackson and LPM Cassandra Harris conducted an unannounced annual visit to the facility at 10:05 am. Upon approaching the facility, LPAs observed the COVID signs on the door. LPAs and LPM were greeted by caregiver, Restituto (Rusty) Ebora and explained the purpose of the visit. LPA Spaeth observed caregiver was wearing a mask. Caregiver called Administrator Lucia Dela Rea and Administrator arrived to the facility at 10:15 am. LPAs' and LPM's temperature was taken upon entry and recorded. LPA Spaeth observed a thermometer, hand sanitizer, PPE masks, and sign in sheet at the front door. The LPA's and LPM began tour at 10:20 am. LPA Spaeth observed two residents in the family room watching television. LPAs and LPM observed the four resident rooms. All rooms contained the necessary regulation requirements which include lamp, nightstand, chair and other items needed for the comfort of the residents. LPAs observed the three bathrooms contained the required wash your hands sign, hand soap, paper towels, and trash cans in each bathroom. All parties then were escorted to the garage and LPA observed a refrigerator which contained fresh vegetables, frozen meats and vegetables, canned goods, PPE supplies such as face shields, surgical gowns, and gloves. Administrator unlocked a cabinet which contained hygiene items for residents. Upon entering the kitchen, LPA observed an adequate supply of canned goods in the pantry, fresh fruits, fresh vegetables, dairy products in the refrigerator. The frozen section of the refrigerator contained frozen meats and vegetables. LPA Spaeth observed the knives were locked in a kitchen drawer and cleaning supplies were locked under the kitchen sink. At 10:17 am, LPAs and LPM observed the staff room which was not locked. LPAs observed the caregiver was not in the room and saw a bottle of rubbing alcohol and a bottle of medication was sitting in the room. LPAs informed Administrator that the staff room should be locked at all times. The staff room was locked by Caregiver at 10:30 am. At 10:25 am LPAs entered a bathroom which residents will use the toilet and sink when needed. LPA Spaeth tested the water temperature and recorded the temperature was 136.5 F. LPA stated to Administrator the water temperature should be between 105 to 120 degrees F. LPA Spaeth stated to Administrator best practice would be to check the water temperature each week. Administrator stated will make sure the water temperature will be checked each week. Also LPA Spaeth observed the shower did not contain a slip resistant mat. At 2:20 pm Administrator purcahsed non slip mats and added to the bathroom. LPAs and LPM were then escorted to the garage and observed the Caregiver took a key off a nail on the wall to open the garage. Upon entering the garage, LPA observed laundry detergent was not locked within the garage. LPA Spaeth explained the key should be stored in a secure area out of reach of the residents. LPA Spaeth also explained since there are two dementia residents living the facility, the keys need to be stored in a secure location. Administrator then removed the key from the wall. At 10:47 am LPAs and LPM observed the staff and resident files were stored in an unlocked cabinet in the dining room. LPA Spaeth stated to Administrator that all records must be locked and secure. Also, LPAs observed the medication cabinet was not locked. LPA's reminded Administrator medication cabinet should be locked when not in use. At 11: 44 am, LPA Jackson reviewed resident files and observed there were two hospice care plans for R1 and R2. Postural support documentation was missing for R3 through R6. Under Title 22 General Regulations, the following citations were issued and recorded on LIC 809D.the state’s words, verbatim · CDSS document, Sep 16, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 16, 2021

87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary . at all times. Maintenance shall include..maintenance services & procedures for the safety and well-being of residents, .... This was not met based upon: LPA Spaeth observed the key to the garage was accessible to residents, which contained cleaning supplies. Also, the staff room was unlocked and contained medications and rubbing alcohol.the state’s words, verbatim · CDSS document, Sep 16, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 27, 2021

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing .. records and for safeguarding the confidentiality of their contents. This was not met based upon: LPA Spaeth observed the file cabinet which contained resident records was not locked.the state’s words, verbatim · CDSS document, Sep 16, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 16, 2021

Faucets used by residents for personal care ...shall deliver hot water. Hot water temperature controls shall be ...automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F .. and not more than 120 degree F ... This was not met based upon: At 10:25 am, LPA Spaeth tested the water temperature in bathroom one which read 136.5the state’s words, verbatim · CDSS document, Sep 16, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 27, 2021

87633 Hospice Care of Terminally Ill Residents (4) A written hospice care plan which specifies the care, services, and necessary medical intervention .. to supplement the care & supervision provided ...is developed for .. resident .. by that resident’s hospice agency & agreed to by the licensee and the resident, .. if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This is based upon: LPA Jackson reviewed the resident files and observed the hospice plan was missing from the file.the state’s words, verbatim · CDSS document, Sep 16, 2021