complaint·December 22, 2022

LPA observed a locked drawer in resident bathrooms to lock up hygiene items. LPA learned through interview that employees have observed, at times, not all items locked up. When LPA toured memory care with the Memory Care Director, she observed unlocked hygiene and grooming items in apartments 163, 168, and 176(pictures taken). Based on the LIC602 of R2, resident is at risk if allowed direct access to personal grooming and hygiene items. Therefore, the allegation that the facility does not make dangerous items inaccessible to residents is SUBSTANTIATED. As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. LPA reviewed training records for the Resident Care Coordinator. Based on the records, LPA has determined that this staff is sufficiently trained to administer medications. Through interview, LPA learned that the RCC will substitute as a med tech when there is a gap in the schedule. RCC will do this in memory care and on the assisted living side of the facility. Based on limited information given in the complaint, LPA was unable to specifically investigate the allegations: facility is not accurately and timely dispensing medications to residents and facility is not accurately maintaining resident records. However, med techs interviewed stated that if a medication was late or not given, staff are to write a reason why on QMar. All staff interviewed stated that there have not been any occurrences of medications being given untimely or inaccurately. All staff interviewed acknowledged that the facility utilizes two radio channels to communicate. Channel 1 is for all staff to hear, only resident apartments are used, no specific or confidential information is given. If two staff members wish to have a semi-private communication, they change to channel 2. At this point, only the two staff members can hear the communication. All staff interviewed stated that they have not heard any resident personal information communicated over the radio. During both tours of the memory care unit, LPA observed the common areas to be clean and orderly (pictures taken). The dining room appeared to be clean and sanitized (pictures taken). LPA observed the following in resident apartments: beds made, rooms organized and bathrooms tidy (pictures taken). LPA discussed R4 with staff. All memory care staff that were interviewed acknowledged that they follow a list of foods for R4 that was provided by their family. All staff interviewed stated that R4 is offered entrees for each meal and dessert. No interviews acknowledged that R4 is only provided sweets or desserts for meals. LPA discussed the staffing schedule with the Administrator and Memory Care Director. All staff interviewed stated that they are sufficiently staffed to meet the resident’s needs. This facility utilizes a staffing agency to assist with any staffing shortages. Additionally, all staff acknowledged that if residents are on a bathing or toileting schedule, staff will follow this schedule. If a resident refuses to be toileted or showered, staff will try again later in the shift. The memory care unit is staffed as follows: AM shift: 1 med tech, 3 caregivers, activity director; PM shift: 1 med tech, 3 caregivers; NOC shift: 1 med tech, 2 caregivers. Additionally, the assisted living staff will help memory care as needed. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility