Complaint·January 17, 2024

The investigation revealed the following: Regarding the allegation "Facility is not following Emergency Disaster Plan protocols," it is being alleged that the facility does not have a register of residents that indicates each resident’s location and ambulatory status readily available to first responders and that staff do not know what to do during emergency disaster drills. Record reviews indicate that the facility maintains an updated register of residents that indicates residents’ location and ambulatory status. During today’s visit, LPA requested the register of residents from the facility’s Administrator and Concierge, and it was provided on both occasions. Interviews with the Administrator and Director of Resident Care indicated that the register of residents will be provided to first responders. Record reviews indicate that fire safety and disaster trainings provided by outside vendor included instructions on how to evacuate residents during emergencies. LPA conducted record review of emergency disaster plan and observed that the facility has an evacuation procedure plan in place. Staff interviews indicated the following: Seven out of seven staff were able to explain their roles during emergencies. Resident interviews indicated the following: Six out of ten residents indicated that, although they feel that the drills were chaotic when conducted, they feel that they would receive help in an emergency. Four out of ten residents were not available. Regarding the allegation " Facility is not following Emergency Disaster Plan protocols," the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Lilit Mnatsakanyan.