complaint·July 2, 2021

Interviews confirmed that some of the high-functioning residents and various families opted for the rooms to be locked for privacy reasons. Interviews confirmed that the locking of resident doors prevented other residents from mistakenly taking something from another resident's room. Prior to this allegation, the resident doors were equipped with a mechanism where residents could lock their door from the inside yet were able to release the lock once they attempted to leave their room. However, the community recently changed the mechanisms on most resident doors and the doors no longer lock. For those whom are high-functioning and are able to keep their own key to their room, the mechanism stayed the same. During today’s visit and the visit conducted on 5/27/2021, the LPA did not observe any locked resident doors. However, the empty rooms designated as ‘Welcome’ rooms were locked from the exterior. Hence, the LPA tested the single-lock system in those rooms. Whereas the doors were locked from the outside, the lock was disengaged once the LPA turned the handle and the LPA was able to successfully leave the rooms. Based on the information obtained, there is insufficient evidence to support the claim that residents were locked inside the rooms. Whereas there was a concern with some residents not appearing physically or cognitively able to open the doors, residents are afforded privacy and are able to shut their door as needed, whether the door is locked or unlocked. Staff also communicated that they conduct regular checks on residents to identify if they need any assistance. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Insufficient staffing It was alleged that there were not enough staff to assist the residents. Interviews confirmed that recently, the community adjusted their schedule and the community implemented a ‘Four/Two’ schedule, where staff work a staggered four days on, two days off , schedule to ensure that there is adequate coverage throughout the week. This adjustment was made because the community discovered that most of the schedules were Monday-Friday, and it was adjusted to provide equal staffing throughout the week. Thus, the new schedule has provided sufficient coverage for all days. The LPA reviewed an accurate staff schedule from May 2021, and observed that on average, the AM shift had 5-6 care staff on shift, which equated to approximately a 1:7 staff to resident ratio. The PM shift had, on average, 4-5 care staff on shift, which equated to approximately a 1:10 staffing ratio. These numbers did not include medication technicians, nurses, or management staff, whom were also trained to provide care. During today's visit and the visit conducted on 5/27/2021, the LPA observed a sufficient number of staff either providing care, assisting residents in the dining rooms, or walking through the hallways. Based on the investigation, there is insufficient evidence to support the claim that the facility was insufficiently staffed. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Residents did not have access to their rooms. It was alleged that because the resident rooms were locked, residents did not have access to their rooms. Interviews conducted and observations confirmed that if a resident needed access to their room, they can alert a staff person for assistance in unlocking their door. In addition, it is common for residents to congregate in common spaces throughout the facility, and some residents are out of their room for most of the day. Interviews confirmed that the locking of resident doors prevented other residents from mistakenly taking something from another resident’s room and was also the preference for some residents. In addition, there were some high functioning residents whom have their room keys on their neck and have access to their room as desired. Based on the investigation, there is insufficient evidence to support the claim that residents did not have access to their rooms. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Residents are not being adequately supervised. It was alleged that residents were kept locked in their room due to insufficient staffing and to prevent residents from wandering into other resident rooms. Interviews and observations conducted revealed that residents were not being locked in their room; however, resident doors were locked in order to prevent residents from unknowingly or mistakenly wandering into someone else’s room. The community had experienced challenges with this behavior in the past with resident items going missing, hence in a way to protect resident items not going missing, resident rooms were locked from the exterior. However, residents were provided access to re-enter their room at any time, as all staff had a master key to unlock the rooms. During today’s visit and the visit conducted on 5/27/2021, the LPA did not observe any locked resident doors. However, the empty rooms designated as ‘Welcome’ rooms were locked from the exterior. Hence, the LPA tested the single-lock system in those rooms. Whereas the doors were locked from the outside, the lock was disengaged once the LPA turned the handle and the LPA was able to successfully leave the rooms. As such, even if residents were in their room, they were able to leave at their own accord. Based on the information obtained, there is insufficient evidence to support the claim that residents were not being adequately supervised. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.