Complaint·May 8, 2025

Staff do not timely respond to a residents alerts Interviews conducted with Executive Director and Staff members S1 and S2 indicated that staff are responding to call button pushes in a timely manner. LPA reviewed call button time logs which indicated that Resident R1 would frequently push their call button and staff responded timely. Interview with R1 indicated that when R1 pushes their call button, the staff respond within reasonable time frames. In review of five (5) resident call button logs, the average response time after a resident pushes their call button was five (5) to ten (10) minutes. Staff do not meet a resident’s incontinence needs Interviews with Executive Director and Staff Members S1 and S2 indicated that Resident R1 has incontinence. Staff follow incontinence care plan and assist R1 with toileting at least every two (2) hours or as requested. Interview with R1 indicated that they need assistance to the toilet and can use their call button to request assistance. During multiple visits with R1, there was no incontinence odor from R1 or R1’s room. Staff do not properly maintain a residents room Interviews with Executive Director and Staff members S1 and S2 indicated that housekeeping and laundry services are provided to Resident R1 weekly as indicated in their admission agreement. LPA observed R1’s room during multiple visits, which was tidy and clean, free of any odor or clutter. Interview with R1 indicated that R1 receives help with housekeeping and laundry services and does not have any complaints. In review with R1’s individualized service plan, R1 is able to maintain independence with housekeeping and laundry other than weekly services. Observation of five (5) resident rooms indicated that staff were properly maintaining resident rooms and assisting with cleaning as needed. **Report continued on 9099-C** Staff threatened a resident while in care LPA conducted interview and learned that S1 made a comment to R1 asking R1 why they didn’t like S1. There are multiple accounts of how the comment was received and its intention. There is insufficient evidence that S1’s comment was intended to be threatening towards R1. Staff did not meet a resident’s hygiene need LPA observed shower skin sheets completed by facility when each resident receives a shower. LPA observed R1 receives showers 2-3 times weekly and it is documented in facility charting notes when R1 refuses to shower. Observations of R1’s person and room indicated that R1 had sufficient hygiene and was free of any odors. Interview with R1 indicated they are receiving showers at least two times a week and did not have any complaints regarding hygiene needs. During tours of the facility on different dates, LPA observed residents in care to be free from odor and have sufficient hygiene. Staff failed to timely seek medical attention for residents LPA reviewed records and conducted interviews. Interviews indicated that facility policy is that when it is determined a resident is in need of emergency medical attention, the facility initiates emergency services. The Department was unable to determine through interviews and documentation if the facility failed to seek timely medical attention for R1. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Staff did not provide appropriate laundry services for a resident Interviews with Executive Director and Staff members S1 and S2 indicated that housekeeping and laundry services are provided to Resident R1 weekly as indicated in their admission agreement. LPA observed R1’s room which was tidy and clean, free of any odor or clutter. Interview with R1 indicated that R1 receives help with housekeeping and laundry services and does not have any complaints. Records reviewed indicated that R1 has laundry service and housekeeping once a week per the admission agreement. In review with R1’s individualized service plan, R1 is able to maintain independence with housekeeping and laundry other than weekly services. Staff are not properly trained Interview with Executive Director (ED), Staff member S1 and S2 indicated that all staff are trained when first hired and continually receive trainings in order to keep skills up to date. ED, S1 and S2 all indicated that staff attend trainings done by facility or by outside agencies. S1 and S2 often oversee staff members in order to ensure that they are following proper techniques that were learned in trainings. LPA observed training records for staff which contained trainings completed by staff. Staff completed trainings on transferring residents in care in and out of vehicles and lifting and transferring of residents (training completed by Vitas Hospice). Staff did not ensure a resident attended scheduled appointments Interviews with the Executive Director (ED) and Staff members S1 and S2 indicated that Resident R1 attended scheduled appointments. ED, S1 and S2’s interviews all indicated that R1 sometimes does not want to attend the scheduled appointment or want to get dressed/groomed to leave the facility for their appointment. Facility staff attempt to encourage R1 to go to their appointments but cannot force R1 to attend. In review with R1’s individualized service plan, R1 is independent with healthcare appointments and transportation or is assisted by family. **Report continued on 9099-C** Staff did not properly report incidents with authorized representatives In review of charting notes from facility dated 8/16/2024- 3/5/2025, facility staff documented when they spoke to R1’s RP each time an incident or event happened either via phone or in person when they arrived. Interviews with Executive Director and Staff Members S1 and S2 indicated that R1’s Authorized representative was notified of any incident involving R1, including refused showers, refusal to leave their room for meals, etc. Interview with R1 indicated that they spoke with their authorized representative and the authorized representative knew about incidents or any changes for R1 based on facility staff informing them. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Interviews conducted with Resident Care Coordinator and Health Services Director indicated that R1 did have an injury sustained during a transfer. R1 sustained a skin tear on the front lower leg. Records reviewed indicated there was an incident report written regarding injury sustained during transfer. Based on the information obtained for the allegation above, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights were provided.