complaint·July 2, 2021

Staff agreed that at times, some residents refuse to be changed, but they try multiple intervention methods to ensure that resident needs are tended to in a timely manner. Interviews revealed that some residents will have accidents due to their dementia diagnosis, but the facility staff will clean the area immediately. The majority of staff believe that the caregivers are responsive in meeting the toileting needs of the residents and are communicative with one another if they need assistance with changing or refreshing a resident. Based on the information obtained, there is insufficient evidence to support the claim that the staff do not meet the incontinent needs of the residents. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff are not meeting residents' showering needs. It was alleged that residents are not receiving their showers. Interviews revealed that most of the residents in the facility need assistance with bathing, dressing and grooming. However, residents will often refuse a service and in such cases, staff employ a number of interventions to ensure that resident care needs are met in a timely manner. Staff claimed that if they are unsuccessful with showering a resident, they will elevate the concern to management or a facility nurse to mitigate the challenge or will enlist the assistance of another caregiver. Staff feel that whereas it may take longer to meet all resident needs, they ensure that residents are treated with dignity and that all hygiene needs are met as described in their care plans. Based on the information obtained, there is insufficient evidence to support the claim that staff are not meeting residents’ showering needs. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility has vermin It was alleged that there was a rattlesnake and a tarantula on the premises and the facility has not done a good job at keeping vermin out of the facility. Interviews and documentation revealed that they contract with Skyline Pest Control to routinely treat the facility. In addition, the facility is surrounded by mountains and wildlife and it is challenging to mitigate environmental circumstances. However, documentation confirmed the facility is making a continuous effort to keep the facility free from pests and insects at this time. Interviews confirmed that vermin have made it into the parking lot and the courtyard, but it is handled immediately. Based on the information obtained, there is insufficient evidence to support the claim that the facility has vermin. The allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is not maintained in conformity with fire safety regulations. It was alleged that the resident windows are sealed shut, and residents would be trapped in their rooms in the event of a fire. Interviews, observations and records review confirmed that the windows in resident bedrooms open up several inches. Documentation review confirmed that the community has not altered any of the windows since the building received fire clearance in September 2017. As such, observations confirmed that resident windows are not sealed shut. Interviews confirmed that the community conducts monthly emergency drills and have dedicated evacuation points in the event of an emergency. In addition, the facility provided documentation that demonstrated that the Fire Marshall inspects the community annually to ensure it is in compliance with fire safety regulations. Based on the information obtained, there is insufficient evidence to support the claim that the facility is not maintained in conformity with fire safety regulations. The allegation is deemed Unsubstantiated at this time. Regarding the allegation: Residents eloped from facility. It was alleged that two residents eloped from the facility. Interviews confirmed that there were two residents (R1, R2) whom made attempts to leave the facility, yet they were observed attempts and the residents were safely brought back into the community. Interviews confirmed that on approximately 10/17/2020, R1, whom was high functioning, took off a window screen from a resident’s room, and egressed into the parking lot. However, staff were immediately alerted to this and redirected R1 back inside the community. Interviews confirmed that on 11/3/2020, R2 also climbed out a resident window, but it was into the secured courtyard, and staff were able to safely assist R2 back into the community. Since these incidents, all windows have been secured. The facility submitted incident reports for the occurrences. Based on the information obtained, there is insufficient evidence to support the claim that residents successfully eloped from the facility, as each of the described incidents were attempts and the staff were able to immediately intervene. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.