Complaint·March 20, 2025

R3 was qualified to be oriented during an interview. R3 did not have any concerns with the lack of care and noted staff would assist within a reasonable time. One source revealed management had discussed call button response times with the facility's receptionist. The call button calls went to the receptionist and the receptionist relayed the calls to staff. Management believed the receptionist was not relaying the calls to staff; therefore, response times were high. This source confirmed the receptionist did relay the calls to floor staff, and several residents and family members had reported concerns with how long it took staff to respond. The response time ranged from five minutes up to forty minutes. Additional interviews with internal sources corroborated several residents had disclosed concerns with how long it took staff to respond to calls for assistance. An additional source reported response times for incontinence care could be up to thirty minutes. Based on the evidence obtained, the allegation was substantiated. It was alleged staff did not treat a resident with dignity. It was reported to the Department staff made Resident #1 (R1) feel ashamed when R1 requested assistance. An interview with one source revealed staff had made comments about having to assist R1. These comments were not made in the presence of R1, but the comments gave the impression staff did not want to assist R1. An interview with R1 confirmed staff had not refuse to assist R1, but staff had made comments that made R1 feel ashamed to ask for assistance with incontinence care. R1 did not report this concern to management. An interview with an external source, who regularly visited the facility, reported some residents had reported concerns regarding staff interactions, including staff not treating residents with dignity. An interview with an additional resident also revealed staff had raised their voice and made condescending comments toward the resident. Although R1 did not report this concern to management, there is enough evidence to substantiate the allegation. The deficiencies were cited in an LIC 9099-D page and a plan of correction was jointly formulated with Executive Director Vonda Boller. An exit interview was conducted with Executive Director Boller, to whom a copy of this report, LIC 811, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided. It was alleged staff did not assist a resident with bathing. It was reported to the Department the facility did not properly assist Resident # 5 (R5) with showers, and this may have led to wounds. Interviews with several internal sources did not reveal any concerns with lack of assistance with showers, nor residents sustaining any wounds as a result. An interview with an external source providing services to R5 reported there were no concerns regarding the facility not assisting R5 with showers. This source also noted there were no concerns with R5 developing any wounds due to inappropriate assistance with showers. One source did report the facility did not assist a resident with showers. Interviews revealed contradicting statements on whether staff did, or did not assist this resident. It was alleged staff did not ensure a resident had clothing. It was reported to the Department the facility did not ensure Resident # 6 (R6) had enough clothing. Interviews with internal sources revealed R6 had enough clothing, but R6 preferred to wear dresses. Sources had witnessed staff redirecting R6 to R6’s bedroom to assist with clothing changes. On one occasion, R6 was witnessed in a common are only wearing undergarments. Interviews with external sources, including an agency providing services to R6, revealed there were no concerns with R6 not having enough clothing. As R6’s health declined, R6 developed anxiety and a concern of R6 undressing was discussed with an external source. It was also revealed the facility communicated with R6’s responsible party to request additional clothing. Interviews did not reveal any concerns with staff encouraging R6 to stay in R6’s bedroom, nor staff preventing R6 from participating in activities and ambulating through the facility. Based on the evidence obtained, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were unsubstantiated. An exit interview was conducted with Executive Director Vonda Boller, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.