complaint·December 6, 2024

Upon review of the staff list at 12:00 p.m. on 09/04/24, it was revealed that S1 was never employed at the facility. R1 did not wish to be interviewed for the investigation. LPA and the administrator reviewed training records which revealed all staff were sufficiently trained in transferring care and up to date on all trainings. Interviews with the administrator at 11:20 a.m. on 09/04/24, the Wellness Director at 11:00 a.m. on 09/11/24, and with Staff #2 (S2) at 12:30 p.m. on 09/11/24 revealed staff are trained for and competent in transferring residents. Interviews with five (05) out of five (05) residents revealed they have had no issues with staff transferring them to and from beds and wheelchairs. Based on interviews and record review, all staff are adequately trained to transfer residents. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not assist residents in a timely manner” it was alleged residents wait up to an hour for incontinence care. Interviews with five (05) out of five (05) residents revealed they have their incontinent needs met in a timely manner. Interviews with the administrator and Wellness Director revealed that resident rooms have pull cords near the bed and emergency pull cords in the bathrooms. Bathrooms emergency pull cords are prioritized higher and staff always respond as soon “within a couple of minutes”. Staff respond to non-emergency pull cord requests based on availability and urgency. LPA tested the facility call system in resident rooms between 12:00 p.m. and 2:00 p.m. on 09/11/24. Four (04) out of four (04) pull cords tested were operable. Staff arrived within five (05) minutes of each request. Based on interviews and observations, staff assist residents in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff does not ensure that the facility is secure” it was alleged residents are not safe because doors are unlocked from the outside. During physical plant tours on 09/04/24 and 09/11/24, LPA observed four (04) out of four (04) exterior side doors to be locked form the outside. The main entrance was unlocked. Interviews with the administrator and Wellness Director revealed that all side doors are locked form the outside at all times and the main door is locked around 5:00 p.m. everyday until about 6:00 a.m. There have been no issues with security or safety. Five (05) out of five (05) residents interviewed confirmed they feel safe and secure in the facility. Based on interviews and observations, staff ensure the facility is secure. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff does not ensure residents are provided adequate food service” it was alleged the facility serves food which is not nutritious. LPA observed lunch service at 11:45 a.m. on 09/04/24 and at 12:15 p.m. on 09/11/24 and observed food to be well-prepared and of adequate nutrition. Meals contained vegetables, proteins, and grains. Daily menus were posted in the elevator and on dining room tables. Interview with the head chef at 11:45 a.m. on 09/04/24 revealed some residents prefer alternatives to the food served, so the facility offers an alternate menu. Five (05) out of five (05) residents interviewed revealed they enjoy the facility food form the main and alternate menus. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.