complaint·February 4, 2025

Regarding Allegation: Staff did not ensure that sharp objects are inaccessible to residents in care. It was alleged that memory care kitchen has sharp items in drawers that residents can reach. Interviewed Health Services Director, Facility Manager, Human Resources Director denied the allegation. Interviewed S1 and S2 stated that they didn't see any sharps in the kitchen / dining area in the Memory care unit that accessible to residents. During today's LPA toured the facility including Memory Care Unit. LPA observed a spray bottle of cleaning supply and Heavy-Duty Construction Caulk Gun in the kitchen cabinet unlocked and accessible to the residents. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . Deficiency is being cited today. A copy of this report, 9099-D and appeals rights were provided. Regarding Allegation: Staff are not responding to residents call button in a timely manner. It was alleged that the pendant response times are almost 45 min when residents call. Interviewed staff denied the allegation. They stated that all the calls go to caregivers pagers and they response time about 10 - 15 minutes and do not exceed more than 15 minutes. Interviewed Health Services Director, Facility Manager, Human Resources Director stated that there is a monitor in the front desk and receptionist can see calls in the monitor. On the monitor shows time of call and the time when it's cleared. Interviewed residents stated that they did not have issues with the response times and stated that staff arrive in a timely manner. They stated someone always response. At the time of tour LPA tested randomly chosen resident's pendant and noticed that staff responded to the calls very quickly. Regarding Allegation: Staff did not ensure that residents physician reports are being updated. It was alleged that LIC 602 /Physician's Reports are not proper at move in and not updated as needed. Staff interviewed denied the allegation. Human Resources Director stated that they don't have incomplete files for residents when they move into the community. Health Services Director stated prior to a person's acceptance as a resident, they obtained documentation of a medical assessment, signed by a physician, and keep on file, review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. Also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. Interviewed S1 and S2 stated that they didn't notice that residents’ files are incomplete and there are missing documents. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegations; 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. Exit interview conducted and a copy of this report was provided.