complaint·May 9, 2023

Allegation: Residents are put to bed early. Based staff interview and residents’ interview, the residents do not have specific bedtime, according to the staff, R2 goes to bed around 7:00pm-8:00pm, R3’s bedtime was around 6:00pm-7:00PM, R4’s bedtime is around 7:00PM, and R5’s bedtime varies between 7:00PM-9:00PM. Based on residents interview, residents stated that they can go to bed whatever time they want and staff are not forcing them to be in bed early. Allegation: Residents are left alone in the facility with no supervision. Based on records review and interview with staff and residents, it was revealed that there is one awake night staff on duty. Night shift starts at around 6:00PM to provide care and supervision to residents in care. Allegation: Facility is not providing resident incontinence care. During the course of interview with residents and staff. The residents stated that staff provide incontinence care at least 2-3x per shift. Staff stated they change the residence at least every 2-3hours per shift. Allegation: Lack of supervision sustaining injury LPA attempted to conduct interview with resident (R1), however R1 was not available for interview. Administrator stated resident (R1) had un-witnessed fall while resident was eating at the dining area. The staff assessed the resident (R1) when resident was found on the floor, based on staff interview there were no injury noted, hospice agency was informed about the incident. Based on records review for resident’s (R1), the care plan did not indicate that R1 was one-on-one care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.