Complaint·July 22, 2025

CONTINUED FROM FORM LIC9099-A Additional witness interviews were conducted during the investigation. Regarding the allegation that Facility failed to ensure oxygen tanks were in working order , the following has been concluded: Witness and resident interviews conducted evidenced that the equipment used by R1 for supplemental oxygen was functioning correctly. However, due to poor vision documented in R1's assessment and evidenced in interviews, R1 would occasionally require staff assistance to operate her small oxygen tank, with occasional excessive waiting times. Issues with oxygen seem to have been solved by the provision of a concentrator. Based on the evidence gathered, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to facility representative. CONTINUED FROM FORM LIC9099-A Additional witness interviews were conducted during the investigation. Regarding the allegation that Residents alerts are not operating while in care , the following has been concluded: Licensing staff conducted multiple visits during which the facility's call system was observed to be in operation. Staff and resident interviews conducted during the investigation did not evidence any period of time during which the call system was not in operation. Additionally, the vendor for the facility provided records of all pendant and pull cords activations for the period of January 2022 corresponding to the allegation being made. A review of the records provided confirmed the statements made indicating an absence of technical issues with the call system. As a result, the allegation is found to be Unfounded, meaning that t he allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Additional witness interviews were conducted during the investigation. Regarding the allegation that Staff are not providing adequate care and supervision to the residents , the following has been concluded: Based on interviews conducted and records reviewed, it was confirmed that on January 28, 2022 at approximately 10:30pm, staff was alerted by another resident's family of an ongoing episode. Staff notes from facility LVN Tiffany Kennebrew are reviewed as follows " Care staff and another resident's family reported that resident was yelling out in hallway. Nurse on duty checked on resident and noted that the resident had increased agitation and oxygen level was below 90%. 911 called to evaluate resident. EMT's reported that resident was having [signs and symptoms] of panic attack [due to] not being able to work portable oxygen machine. Resident refused hospital transport and EMT's educated resident on how to properly work machine. [Daughter] Sherri notified and this nurse asked [daughter] to look into getting a concentrator for ease of use of oxygen therapy ". Due to the resident's assessed vision issues and response delay, facility staff appears to have failed to meet the requirement to ensure the resident could safely operate their oxygen equipment. Regarding the allegation that Staff did not accord resident's with dignity , the following has been concluded: A review of the facility's records for pendant pushes on January 28, 2022 demonstrates that the initial activation made by R1 is timestamped as follows: " 1/28/2022 21:49 [...] Alpers, Helene (lives in Apt 255) 244-2033 from Receiver by 154, [...] Announced 9 times. Healthcare Wristlet 150CD responded at 10:32 p (43 mins). " As R1 was experiencing difficulty in operating their oxygen equipment, R1 had to wait 43 minutes to receive assistance from staff and was observed being agitated in the hallway. As a result, both allegations are found to be Substantiated, meaning that the preponderance of evidence standard has been met. An exit interview was conducted and a copy of this report along with appeal rights was provided and left at the facility.