complaint·February 29, 2024

The investigation revealed the following: Regarding the allegation "Staff did not follow quarantining protocol” it is being alleged that during resident’s quarantining staff refused to enter resident’s room. 3 out 5 residents indicated that staff provided in person services to them during their quarantining. 5 out of 5 staff interviews indicated that for residents who are quarantining, staff go into their bedrooms and provide them with services. Record reviews demonstrate that the facility has a Facility Infection Control Requirements Plan and an Inspection Guidelines for Infection Control. The investigation revealed the following: Regarding the allegation "Facility does not meet resident's incontinence needs” it is being alleged that staff failed to provide incontinence care and due to this a resident developed a UTI and blisters on their genital area. 3 out of 3 residents who receive incontinence care indicated that staff assist them with their incontinence needs. 4 out 4 caregivers interviewed indicated that they check residents every 2 hours but, in some cases, they check them every 30 minutes. Record review shows Resident’s 1 Resident Call Log and Bowel Movement Log and it demonstrates a daily log of how often they are checked and changed. The investigation revealed the following: Regarding the allegation "Staff did not regularly monitor resident for change in condition” it is being alleged that staff did not observe blisters on resident’s genital area. 5 out 5 residents indicated that staff check up on them every day. 4 out of 4 caregiver interviews indicated that they continuously observe their residents for change of condition and if there is a change they notify the medical technician, licensing vocational nurse, or the Administrator. Record Reviews of Resident 1 demonstrate various daily logs of their Resident Call Log, Bowel Movement Log, and Meal/Fluid Intake. The investigation revealed the following: Regarding the allegation "Staff do not answer resident call button in a timely manner” it is being alleged that sometimes staff answers the call button in 30 minutes, and it takes them another 30 minutes to arrive to the residents’ room. 3 out 5 residents who use the call button indicated that they come in a timely manner to their room. 4 out 4 caregiver interviews indicated that they go to residents’ rooms in an adequate amount of time and if they are unable to go then another staff member will assist the resident. LPA checked random call buttons and found that the average response time was in less than 1 minute, there was only one call button that took about 4 minutes for staff to respond. Regarding the allegation "Staff did not follow quarantining protocol,” “Facility does not meet resident's incontinence needs,” “Staff did not regularly monitor resident for change in condition,” “Staff do not answer resident call button in a timely manner” The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator.