complaint·March 23, 2023

(Continued from LIC9099) Residents interviewed confirmed that facility staff were nice and interacted with them in a positive and respectful manner. Staff interviews indicated that residents are treated with positive regard and that staff exhibit patience and enjoy spending time with them. Outside source interviews and witness interviews showed that staff were observed treating residents with respect and in a positive manner. A review of facility records showed that staff complete a series of onboarding and continuous training that reinforces the basic rights of residents and how to interact with residents based on their developmental needs. Staff also agree to community standards which outline specific characteristics of acceptable and expected behavior, which are reinforced by documented performance reviews. During 4 unannounced facility visits LPA observed staff to be engaging with residents in a positive and respectful manner. LPA did not observe any resident reacting to any staff member in a way that would indicate a negative or unpleasant dynamic. LPA observed a poster of staff expectations which address the positive treatment of others to be in a visible location for staff to view regularly. Regarding the second allegation, ‘Staff did not meet resident(s) incontinence needs. Direct observation by LPA as well as outside source interviews, resident interviews, staff interviews, and records review, did not demonstrate that staff are not meeting the incontinence care needs of residents. Resident interviews confirmed that facility staff assist them regularly and timely with their toileting needs. Staff interviews showed that staff are aware of and meet the expectation for residents to be toileted every 1-2 hours, depending on their care plan and individual needs. Outside source interviews and witness interviews showed that there were no concerns regarding staff adhering to the toileting expectations and incontinence needs for residents. Review of facility records showed that staff complete training regarding incontinence care for residents during onboarding and through continuing education. Staff document residents’ abnormal continence patterns, which are reviewed and addressed accordingly by management, based on individual needs. During 4 unannounced facility visits LPA directly observed all residents to be groomed with clean clothing, free from debris. LPA did not observe any odors indicating that incontinence care was not being adhered to. During each visit LPA observed multiple residents being assisted with their toileting needs. (Continued on LIC9099-C...) (Continued from LIC9099-C...) Regarding the third allegation, ‘Staff did not meet resident(s) needs'. Direct observation by LPA as well as outside source interviews, resident interviews, staff interviews, and records review, did not support the claim that facility staff were not meeting the basic needs of residents. Resident interviews confirmed that facility staff assist them regularly and timely with their basic care needs and assist them when they request help. Residents stated staff help them with everything they need, including during the night. Interviews with 7 staff revealed that residents are being helped by staff with Activities of Daily Living (ADL) such as ambulating, eating, showering, toileting, and dressing. Outside source interviews and witness interviews showed that staff were meeting residents’ basic needs according to their care plans and when requested. Review of facility records showed that staff complete training regarding meeting the basic needs of residents during onboarding and through continuing education. The facility has systems in place for resident needs to be met, and for staff to hold each other accountable by directly addressing issues with other staff members, or notifying management. Staff meeting expectations regarding residents’ basic needs is reinforced by documented performance reviews. During 4 unannounced facility visits, LPA directly observed staff walking around engaging with residents, assisting with ADLs, and instructing group activities. LPA directly observed residents asking staff members for assistance and receiving help immediately or within minutes of the request. If a staff member was unable to assist a resident in the moment, LPA observed the staff member communicate the delay to the resident and return to help or call for another caregiver to assist. LPA observed residents being assisted by staff with ambulation, toileting and eating. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are therefore UNSUBSTANTIATED. An exit interview was conducted with Cynthia Cranmore, Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.