complaint·July 3, 2025

Investigation revealed the following: #1- Allegation: Licensee does not ensure enough staff to meet residents needs LPA conducted interviews with twelve (12) residents (R1-R12), 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), 9 staff members revealed that there is adequate staffing to meet the residents’ needs, although there may be instances where individuals call out. But alternate measures are taken to maintain adequate staffing daily by calling backup staff for coverage. 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. #2- Allegation: Staff leave residents soiled for an extended period of time LPA conducted interviews with twelve (12) residents (R1-R12), and 9 out of 12 residents reported that they are not left soiled for an extended periods, with staff checking on them every 2-3 hours or as needed. 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 stated residents are routinely checked on every 2-3 hours across all shifts to help the residents in care and or as needed. #3- Allegation: Staff are not properly supervising residents who may be a fall risk LPA conducted interviews with twelve (12) residents (R1-R12), and 9 out of 12 residents stated that they receive assistance with their needs, and the staff members are always encouraging them to use their ambulation devices to avoid falls. 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, encouraging residents to use their walkers, and assisting residents requiring care or support, contributing to fall prevention. LPA also noticed staff members assisting residents in the common area during the visit. Interviews with nine (9) staff members (S1-S9) further stated staff members encourage and implement appropriate measures to ensure residents, including those at risk of falling, are properly supervised to prevent falls. Furthermore, staff stated residents are regularly checked on every 2-3 hours across all shifts to provide necessary care and support. #4- Allegation: Staff are not answering call buttons in a timely manner LPA conducted interviews with twelve (12) residents (R1-R12), and 9 out of 12 residents reported receiving assistance with their needs, with staff checking on them every 2-3 hours or as needed. Residents also stated 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) stated 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 If staff members are occupied assisting others, alternate measures are taken by other staff to ensure residents receive timely 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.