Complaint·May 20, 2025

One source reported it could be frustrating to communicate with one of the staff members, but this source also disclosed there were multiple staff present to address any misunderstanding. Additionally, the LPA conducted interviews with facility staff and was able to hold conversations.The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged the facility did not have auditory devices at exit doors. On August 26th, 2024, it was reported to the Department several exit doors at the facility did not have auditory devices. During an unannounced visit, the LPA witnessed several exit doors did not have auditory devices. The LPA also witnessed several of the exit doors were covered with plastic coverings. An interview with the administrator revealed the facility was in the process of painting a portion of the facility and some of the auditory devices were removed to avoid any damage to the devices. Records reviewed for the four residents in care revealed one resident was diagnosed with Mild Cognitive Impairment (MCI), but did not require assistance with activities of daily living and could leave the facility unassisted. One resident was diagnosed with dementia but required assistance transferring out of bed. Two residents were diagnosed with MCI and one required assistance with transferring out of bed. The second resident with MCI was ambulatory and could be confused at times. Per Dementia Care regulations, the facility must have auditory devices, or alert features to monitor exit doors when residents are at risk of elopement. There were no noted behaviors of wondering, or elopement from any of the residents, and the resident diagnosed with dementia required assistance with transferring out of bed. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged the facility did not have sufficient staff to meet a resident’s needs. On August 26th, 2024, it was reported staff did not respond to assist a resident, because there was insufficient staffing. Interviews with internal and external sources did not have any concerns with staff not having sufficient staff. Interviews with the administrator and staff revealed the facility did not maintain hard copies of schedules, but there were two to three staff working the first shift from 7 AM to 7PM. There were at least two staff at the facility during the second shift from 7 PM to 7AM. (See additional LIC 9099-C for continuation of report.) The administrator resided at the facility and would assist when needed. Review of resident records revealed there were four residents residing at the facility. One resident did not require assistance with activities of daily living and was independent. The remaining three residents required assistance with transferring, dressing, bathing, and toileting. One of these residents employed a private caregiver Monday through Friday from approximately 9 AM to 5pm. Based on the evidence obtained the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. It was alleged staff did not follow an admission agreement. On August 26th, 2024, it was reported to the Department that the facility did not assist Resident # 1 (R1) with daily exercises, nor room cleaning as indicated in the admission agreement. Staff reported staff would attempt to clean R1’s bedroom on a weekly basis, but R1’s spouse, who also resided at the facility, would decline and discourage staff from assisting R1. Staff would assist R1 with exercises, but R1’s health had declined and R1 spent more time sleeping or sitting on R1’s chair. Interviews with additional internal and external sources did not have any concerns with lack of bedroom cleaning, nor with the admission agreement not being followed. Based on the evidence obtained, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Ray Baha, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058),were provided.