Complaint·March 11, 2025

While this behavior could be perceived as aggression, it is actually an attempt to facilitate communication with the residents who struggle to hear. Furthermore, S5 recounted an incident involving a former staff member, who reported witnessing another staff member (S2), tapping on a table in an effort to gain the attention of a resident. S5’s investigation confirmed that S5’s action was intended to call the resident to the table for a meal, not to display aggression. S5 emphasized that this behavior was not aggressive in nature but rather a means of communication with a resident who had hearing issues. In addition, S7 acknowledged that staff sometimes raise their voices when interacting with residents who are combative or aggressive towards them. However, S7 clarified that this is done as a response to the resident’s behavior and is not intended to be malicious. The goal is to de-escalate the situation and ensure safety for both the resident and staff. An interview with the Ombudsman, who conducted an observation at the facility on 11/14/24, further supported the absence of aggression in staff interactions with residents. The Ombudsman reported no observed instances of staff being aggressive towards residents during their visit. Finally, observations conducted by this LPA during facility visits on 11/14/24, 12/17/24, and 3/11/25 did not observe aggressive behavior by staff towards residents was noted. Based on the gathered evidence from interviews and observations, there is no substantiated claim of staff aggression towards residents in care. Reports suggest that behaviors that may be perceived as aggressive were, in fact, attempts to communicate with residents or respond to challenging behaviors, with no intent to harm or intimidate. Therefore, this allegation was UNSUBSTANTIATED. An unsubstantiated finding means 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. {2 of 3} Allegation: Facility is not adequately staff to meet the needs of residents in care. The investigation into this allegation included interviews with staff members and a review of staffing records for October and November 2024. Interviews with staff members (S5-S9) collectively revealed that the facility is sufficiently staffed and that there are no significant staffing issues. The staff reported that, in the event of staff call-outs, supervisors are typically available to step in and assist with caregiving duties when necessary. Additionally, they confirmed that there are two care staff members assigned to the Memory Care unit during both the AM and PM shifts, as well as two care staff members in the Assisted Living area for each of those shifts. For the NOC shift, there is one care staff member assigned to both the Memory Care and Assisted Living units. Each shift also includes one med tech who covers both the Memory Care and Assisted Living areas. S5 further explained that, in addition to the caregiving staff, other team members such as kitchen and housekeeping staff provide additional support to ensure the well-being of residents. Furthermore, the Memory Care Coordinator is available to cover the mid-shift, offering further assistance and oversight. A review of the staffing schedules for October and November 2024 confirmed the information provided by staff. The schedules show that the staffing levels meet the reported staffing assignments, with two care staff in both Memory Care and Assisted Living for the AM and PM shifts, one care staff for the NOC shift in each area, and one med tech per shift covering both units. Based on the evidence gathered through interviews and record review, this allegation is UNSUBSTANTIATED.Note: an unsubstantiated finding means 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. Exit interview was conducted and a copy of this report and appeal rights were provided. {3 of 3} A review of the training records for staff members (S1-S5) confirmed that they are consistently receiving monthly training through the Relias platform. Specifically, S1’s training records included a range of relevant and comprehensive topics such as dementia-related education, first aid, medication management, infection control, environmental cleaning, hospice care, cultural awareness, fire safety, abuse prevention, monitoring changes in residents' conditions, and resident rights. For staff members S2 and S3, additional evidence of training was provided. S2's training in 2024 included orientation sessions with various department directors. These included training on activity programs and the memory care program with the Activity/Memory Director, meal services, special diets, kitchen sanitation, and food storage with the Culinary Director, and assessment and care plan procedures, change in condition, incident reporting, fall risk management, medication administration, and infection control with the Resident Care Coordinator. S2 also received orientation from the Maintenance Director on housekeeping services, laundry, maintenance, emergency procedures, fire safety, and life safety, as well as training from the Business Office Manager on abuse/neglect policies, workplace violence policies, job descriptions, and resident safety. Finally, S2 received orientation from the Executive Director on job descriptions, responsibilities, and resident rights. Based on the interviews and record reviews, it is evident that staff members at the facility receive adequate and ongoing training. Therefore, this allegation is UNFOUNDED. *************************************************************************************************************************** Allegation: Facility staff do not follow safety practices of the facility. An investigation was conducted to determine whether facility staff are adhering to the safety practices of the facility, particularly wearing the appropriate attire while on duty. This investigation included interviews, observations, and a review of relevant records. Interviews with the Ombudsman revealed that during their observation on 11/14/24, Ombudsman did not observe any instances of staff failing to follow safety practices, including wearing inappropriate attire while on duty. Additionally, interviews with staff members (S5-S9) confirmed that they are required to wear a uniform provided by the facility, which includes a scrub top, black pants, and slip-resistant, closed-toed shoes. {2 of 3} A review of the facility's Appearance and Grooming requirements for Personal Care Assistants further supported these findings. The policy specifies that staff members must wear company-issued uniforms, black pants (excluding jeans, scrubs with ties, or leggings), and appropriate black, closed-toed and heeled shoes. This policy aligns with safety standards to ensure staff are properly attired to perform their duties safely. Additionally, a review of the company policy on slip-resistant footwear confirmed that the footwear required meets or exceeds ASTM safety standards. These shoes are designed with outsoles that provide traction on slippery floors and surfaces, further enhancing staff safety while performing their duties. Finally, during facility visits on 11/14/24, 12/17/24, and 3/11/25, the LPA conducted observations and did not note any staff members wearing inappropriate attire or deviating from the facility’s appearance and grooming policy. Based on the evidence gathered from interviews, observations, and record reviews, staff members were observed adhering to the facility's uniform policy and safety requirements, and there were no violations noted during the investigation. Therefore, the allegation that staff do not follow safety practices, particularly not wearing appropriate attire is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. Exit interview was conducted and a copy of this report was provided. {3 of 3} Additionally, the Ombudsman interviewed staff member S1, who revealed that staff had not updated some residents' "Life Story Books", particularly for residents who have been at the facility for a longer duration. These books are meant to provide essential personal and life history information to ensure individualized care, but it appears they have not been regularly updated, especially for long-term residents. Based on the evidence gathered, it is substantiated that the facility has not been updating resident records, including both physician reports and life history documentation. Therefore, this allegation is SUBSTANTIATED. Note that the facility has been cited during their annual visit on 11/17/24 and deficiencies has been cleared. Exit interview was conducted and a copy of this report was provided. {2 of 2}