complaint·May 16, 2024

Allegation: Residents are not provided with activities. It was alleged that during six random visits conducted from 09/17/21 - 03/16/22 the facility did not provide any Activity to the residents and no Activity schedule was available for review, upon request. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that the facility posts monthly Activity schedule for the residents in Memory Care Unit and Assisted Living. LPA was also informed that during the time mentioned above, the facility followed COVID protocol regarding minimizing big/long gatherings to protect residents health and well being. Moreover, interview with the Administrator revealed that Activities for the residents were never stopped completely. In addition, LPA was able to interview eight (8) out of twelve (12) residents and all residents interviewed expressed no concerns regarding the above allegation. Lastly, during todays visit, LPA observed thirteen (13) Memory Care Unit and twelve (12) Assisted Living residents engaging in a daily activity. Based on interviews, record reviews and LPA observation this allegation is deemed Unsubstantiated at this time. Staff isolate residents. It was alleged that the facility isolated residents between 09/17/21 - 03/16/22. To investigated this allegation, LPA conducted an interview with the Administrator and was informed that the facility always has enough staff members to provide care and supervision to residents in a Memory Care Unit. LPA was informed that due to Covid pandemic, frequent isolation was followed by the Department of Health. Interview with the Administrator also revealed that the facility staff respect all residents' personal rights and will attempt, but not force residents to commingle and or participate in certain activities. Moreover, interviews with two (2) staff members revealed that some residents, in a Memory Care Unit, like to be left alone. Although, the staff will redirect them to engage in communication or other activities, some residents may continue to and have a right to refuse. Lastly, during the visit, LPA observed staff members redirecting residents into common areas of the facility. Based on interviews, record reviews and LPA observation this allegation is deemed Unsubstantiated at this time. Continue on LIC9099-C Staff do not maintain accurate records. It was alleged that the facility Memory Care Unit has no rooms labeled with resident names and the census don’t match the residents who are actually in the room. To investigate this allegation, LPA conducted a tour in a Memory Care Unit on 05/16/24 and observed all resident rooms labeled with names, however, some labels are removed/torn/damaged. Interview with the Activity Director and two (2) staff members revealed that due to R1's mental condition, R1 remove/damage labels. However, once the staff is aware of that, they inform the management, and a new label is created and placed at the door. Interview with the Administrator revealed that residents would periodically remove the names from the individual rooms, however, that was never an issue for the facility staff to replace it with a new one. Administrator also informed LPA that R1 removes all labels and the facility is now working on replacing the labels with something different that cannot be damaged/torn/removed. Moreover, Administrator denied the above allegation and stated: “All resident names always matched/matches the facility census.” Lastly, during today’s visit, LPA confirmed that a Memory Care Unit residents, who are in the room, match with the facility census. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Staff lock residents in their rooms. It was alleged that residents in a Memory Care Unit are kept locked in their rooms. To investigate this allegation, LPA conducted an interview with the Administrator and an Activity Director. Both parties denied ever witnessing or hearing residents being locked in their rooms. LPA was informed that the doors can only be locked from inside by the resident. However, all staff members have a master key and can easily gain access. Interview with two (2) staff members revealed that a Memory Care Unit currently has five (5) wandering residents. LPA was also informed that when residents are out in common areas all resident doors are kept locked to prevent wandering residents from entering. Interview with two (2) staff and an Activity Director also revealed that all Memory Care Unit residents doors are always unlocked, when the resident is in the room, and the staff checks on them every hour. LPA visited five (5) random rooms and observed that the door has no auto lock and can easily be opened. However, the door is kept locked from the outside and only a staff member with master key can gain access. Therefore, based on interviews, observation and record reviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.