Complaint·January 6, 2024

Investigation revealed the following: Allegation: Staff do not answer residents' call buttons in a timely manner. It was alleged that staff do not answer residents' call buttons in a timely manner. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 3 out of 5 staff (S1, S2, S4) stated the resident’s call button should be answered between 5-10 minutes for a timely response. S1 and S2 stated beyond 10 minutes is unacceptable. S5 stated the usual wait for a resident’s call is between 5-15 minutes while S3 revealed residents usually wait for 5-30 minutes. Based on interviews conducted, 4 out of 6 residents (R2, R3, R4, and R6) admitted they use the call button for help, and they wait between 5-45 minutes, 1 out of 6 (R1) residents stated the wait is up to an hour and 20 minutes. One resident (R5) has not used the call button to call for help. LPA did not obtain any records pertaining to call button incidents. Based on LPA’s observation on 11/8/2023 at around 1:03 PM while testing the call button in room #229B with S2, staff did not respond to the call button within 10 minutes. S2 aborted the test immediately after 10 minutes and called staff by using a walkie talkie. Per LPA’s observations, staff do not always answer residents’ call buttons in a timely manner. Based on information gathered, there is sufficient evidence to corroborate the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “ Staff do not answer residents' call buttons in a timely manner ” is found to be SUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Melanie Heard/RCC Investigation revealed the following: Allegation: Staff do not provide adequate food service to residents. It was alleged that staff do not provide adequate food service to residents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff do not provide adequate food service to residents. They revealed that meals are always served timely. S2 stated every meal has a set schedule both in the dining hall and in room service. Breakfast is ready between 8:00 am – 8:15 am, lunch (12:00 pm – 12:15 pm), and dinner (5:00 pm – 5:15 pm). R1 claimed food is sometimes delivered to the room late. Based on LPA’s record review and observation during the visit, the meals serving time posted in the dining hall is consistent with S2’s statements. LPA observed residents eating in the dining hall at 12:00 pm. LPA also observed a staff delivering a tray of a resident’s meal to bedroom # 229A at 12:11 pm which is within the facility’s meals serving time schedule. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff falsified resident documents. It was alleged that staff falsified resident documents. On 11/8/2023 between 11:55 am – 2:05 pm, LPA Montoya interviewed 5 out of 14 on-duty staff and 6 out of 68 residents. Based on interviews conducted, 5 out of 5 staff and 5 out of 6 residents denied that staff falsified resident documents. R1 claimed R1’s contract has been changed many times and it is not signed by the facility administrator. S1 stated R1 owes the facility in back rent, and it was necessary to amend the contract with the agreement to pay the back rent until the account is current. Based on record review, R1’s lease addendum dated 11/1/2023 pertains to the payment for the back rent and it was signed by a facility representative and R1. During the investigation, LPA did not observe unusual activities by the facility falsifying resident documents. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations, “ Staff do not provide adequate food service to residents”, and “Staff falsified resident documents” are found to be UNSUBSTANTIATED. Exit interview was conducted and a copy of the report was provided to Melanie Heard/CCR