complaint·October 9, 2024

previously obtained from the facility. At the time of this visit at 11:10a.m., LPA Alvizar-Ettima and RCD conducted a physical plan tour. During inspection, at approximately 11:30a.m. LPA attempted to interview nine (09) out of fifty-five (55) residents residing at Generation Unit. However, they were unable to respond to LPA’s questions. 1. Due to insufficient staffing, resident was not checked on time. It was alleged that R1 passed away in their room and staff did not know R1 had passed due to short staffing. S taff interviews reveal that they have sufficient staffing to check on residents timely. Resident Care Director (RCD) indicated that Generation Unit has a total of five (05) staff during the morning and evening shifts. There are three (03) staff during night shift. Residents are being checked out every two hours and as needed. They did not receive any complain about insufficient staffing. During this visit LPA observed residents in Generation Unit and they appeared to be clean and well groomed. A review of facility staff schedule supported the information provided by the staff Based on observation, interviews and records review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Staff locked resident in room. It was alleged that staff would lock resident (R1) in room residing on the Generation Unit because R1 was a wander risk. Resident Care Director (RCD) and staff interviews reveal that the residents are not locked in the room. All bedroom 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 three (03) staff that provide care in the Generation Unit revealed that doors are always unlocked, when the resident is in the room, and the staff checks on them every two hours. Some residents carry their own key however they can always open the door from inside the room. RCD and staff indicated that when residents are out in common areas all resident doors are kept locked to prevent wandering residents from entering. During inspection, LPA visited five (05) random selected rooms including R1’s 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. Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard are noted during this visit. Exit interview is conducted and copy of report was provided.