complaint·August 23, 2024

LPA reviewed and verified 11 employee's training was completed in this area. Device Activity Reports for facility call buttons and pendants dated 8/13/24 and 8/22/24 revealed that 55 alarms were pulled and of the 55, 14 alarms were cleared upon departure of assisting resident rooms while remaining 41 were cleared upon arrival. Upon review facility August in service meeting dated 8/22/24 reveals training was conducted regarding pendant response time informing staff to clear pendant as soon as enter room. Training also revealed for staff to ensure to monitor pendants ideally within 10 minutes. Interviews conducted with staff revealed that twelve of twelve staff members state they are to clear pendants and pull cords in a timely manner within 10 minutes. Staff interviews indicated that twelve of twelve staff confirm if staff member are unavailable at time call received, staff are to communicate with care team via radios so that other available staff members can assist residents. All staff interviews revealed facility has coverage of staffing to assist with residents needs. Staff interviews confirm facility uses registry for coverage. Interviews conducted with residents revealed that eight of eight residents confirmed that staff responded to their call buttons in a timely manner of five to ten minutes. Resident interviews revealed that residents do not have issues with staff and facility has adequate staff on the floor. Five of eight residents confirmed that staff assist residents for dressing, toileting and or showering in timely manner. Based on records reviewed and interviews conducted, 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 following allegations: due to lack of staff, residents are not changed timely and staff do not respond to call bell in a timely manner are deemed UNSUBSTANTIATED. An exit interview was conducted with facility representative and a copy of this report was reviewed and provided at the time of this visit.