complaint·May 22, 2024

. Resident records revealed that six of six residents had resident and or responsible parties signed Admission agreements that included a section regarding Overnight staff which states “ Overnight wake staff is provided at Ever Care when prescribed by a physician, requested by resident or responsible person or when determined by the facility that additional level of care is needed. An additional charge will be assessed by Facility when overnight wake staff is provided.” Interviews conducted revealed the following: three of three staff confirm all residents have a operating call system to which residents can push when needing assistance. Staff interviewed stated they respond to resident call system. Three of three staff stated that during the middle of the night when go to bathroom they conduct resident rounds. Two of three residents interviewed indicated there have been a couple of incidents where either staff did not respond immediately or not at all. Three of three residents interviewed confirmed that facility has staff present at all times and are never left unattended inside facility. All three residents interviewed indicated staff try their best to provide good care. During investigation, LPA pressed alert system buttons to confirm alerts are operational and loud. LPA observed when pressing alert buttons staff responded immediately. Based on records reviewed, interviews conducted, and observations made 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: staff are not available to assist residents at night is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of this report was reviewed and provided at the time of this visit.