complaint·December 22, 2021

The investigation revealed the following: Allegation – Smoking is occurring inside of the facility. It is alleged that staff are smoking in the facility with residents that use oxygen. LPA toured the facility and observed 1 resident using oxygen. There was a sign posted at the front door stating, “No Smoking: Oxygen in Use”. According to interviews with Staff, they do not smoke and understand the danger of smoking while oxygen is in use. Per Co-Administrator, staff never smoke in the facility and if they want to smoke, they may do so outside of the facility in the patio area. LPA interviewed 3 Resident’s family members or friend, and all stated there are no cigarette smell or odor nor seen any staff smoking when visiting. Allegation – Resident’s care needs are not being met. It is alleged that staff are not responsive. The Co-Administrator and Staff interviewed stated they take care of their residents and tend to their needs daily. Staff stated they observe for resident’s behaviors and assist immediately. They check on residents often during the day and at night and change their diapers, feed them, shower them, and administer medications. According to family members interviewed, staff are doing a good job in caring for the residents and are attentive. Allegation - Residents are forced to go to bed at an unreasonable hour. It is alleged that residents need to go to bed at 5pm. Based on interviews with the Co-Administrator and Staff, residents are not forced to go to bed at 5pm. Dinner is served at 4:30pm and after dinner, residents have a choice to go their rooms or stay in the living room. Some will ask to go to their bedrooms, while some stay outside. Residents’ family members and friend interviewed stated that they visit at different times, sometimes in the evenings, and did not see staff forcing residents to sleep. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . An exit interview was conducted with Staff. A copy of this report along with the appeal rights were provided.