complaint·May 21, 2025

Allegation: Licensee does not ensure enough staff to meet residents needs LPA conducted interviews with twelve (12) residents (S1-S12), and 9 out of 12 residents stated the licensee ensures there is adequate staffing to meet their needs. LPA attempted to interview three (3) residents who chose not to participate in the process during the visit. The interviews with nine (9) staff members (S1-S9) all 9 staff revealed that there is adequate staffing to meet all resident needs, although there may be instances where individuals call out. However, measures are in place to maintain adequate staffing daily. LPA also observed the staff schedule for the month of May 2025 which appeared that there is sufficient staff to care for the needs of the residents. Allegation: Staff leave residents soiled for an extended period of time LPA conducted interviews with twelve (12) residents (S1-S12), and 9 out of 12 residents reported that they are not left soiled for an extended period, with staff checking on them every 2-3 hours. LPA attempted to interview three (3) residents who declined to participate in the interviewing process during the visit. Additionally, LPA observed staff performing routine checks and assisting residents who required care or support. Interviews with nine (9) staff members (S1-S9) further indicated that they have not encountered any instances of a staff member or resident reporting that a resident was left soiled for an extended period. Staff confirmed that residents are routinely checked on every 2-3 hours across all shifts to help the residents in care. Allegation: Staff are not properly supervising residents who may be a fall risk LPA conducted interviews with twelve (12) residents (S1-S12), and 9 out of 12 residents stated that they receive assistance with their needs, with staff checking on them every 2-3 hours. LPA attempted to interview three (3) residents who chose not to participate in the interview process during the visit. Additionally, LPA observed staff carrying out routine checks and assisting residents requiring care or support, contributing to fall prevention. LPA also noted staff members assisting residents in the common area during the visit. Interviews with nine (9) staff members (S1-S9) further confirmed that all staff members implement appropriate measures to ensure residents, including those at risk of falling, are properly supervised to prevent falls. Furthermore, staff stated that residents are regularly checked on every 2-3 hours across all shifts to provide necessary care and support. Allegation: Staff are not answering call buttons in a timely manner LPA conducted interviews with twelve (12) residents (S1-S12), and 9 out of 12 residents reported receiving assistance with their needs, with staff checking on them every 2-3 hours. Residents also stated that when they use their call buttons, assistance is provided immediately. If staff members are occupied assisting others, alternate measures are taken by other staff to ensure residents receive timely support. LPA attempted to interview three (3) residents who declined to participate in the process during the visit. Additionally, LPA observed staff performing routine checks and assisting residents requiring care or support. Interviews with nine (9) staff members (S1- S9) further confirmed that all staff members implement appropriate measures to ensure residents receive timely assistance when using their call buttons, including those at risk of falling. Staff also stated that residents are routinely checked on every 2-3 hours across all shifts to provide necessary care and support. Based on observations, record reviews, and interviews with staff members and residents, the evidence gathered during the investigation indicates that the above allegation is unsubstantiated. This means that while the allegation may have occurred or holds validity, there is insufficient evidence to determine whether the alleged violations did or did not take place. An exit interview was conducted where this report was discussed and provided to Helen Lee-Administrator at the conclusion of the visit.