complaint·November 17, 2023

It was specifically alleged that residents’ laundry and trash bins were overflowing. A co-complainant later informed that there were blood stains on resident #2’s (R2) furniture. Interviews with residents said that staff walk throughout the building in the morning and throughout the day to pick up their trash. Normally it would be housekeeping staff who picked up their trash when they cleaned their rooms, but if they have trash to be taken out, residents would place it outside their doors and staff would ensure it is picked up. Interview with staff corroborated the residents’ statements. They have staff conduct their last rounds of morning trash pick-up. The Housekeeping Service Procedures specifically indicate what housekeeping services includes and trash removal was included. Interview with an outside source did not have any concerns. A review of records revealed that the residents have notices posted next to their front door advising them of their assigned housekeeping day including the numbers to the front desk areas. Housekeeping records showed that staff have assigned units and allotted timeframes to ensure each unit has been cleaned thoroughly. The Housekeeping Schedule showed the areas where staff were assigned during the week. There are Independent Living (IL) and Assisted Living (AL) Cleaning Days sheets that separate each floor by section assigned to specific housekeeping staff. Per the cleaning days sheet, staff are assigned approximately 8 rooms daily to clean. The Housekeeping Assignment Sheet log showed that housekeeping staff are in their assigned room(s) for approximately 45 minutes to one hour cleaning their assigned rooms for the day. On November 2, 2023, LPA toured the facility and was able to observe residents’ rooms at random throughout the facility. Each room displayed to be clean and sanitary. There were no trash or laundry that overflowed the residents’ bins. On November 17, 2023, LPA toured R2’s room and did not observe any blood on their furniture. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not provide residents with clean linens. Interviews with residents said that they are provided clean linens weekly or on an as needed basis. Residents had no issues with their linens being unclean. Residents said that they have an assigned laundry day that the care staff follow to launder their clothing. If they have the need to do an emergency wash, they notify the front desk and they will call staff to assist; or they also have the option if they want to launder their clothing themselves. Interview with staff corroborated their statements. Staff also said that caregivers are responsible for laundering the residents clothing by the end of their shift. If the laundry was not completed by the end of their shift, it would then be reassigned to the upcoming shift. (Continue on LIC9099-C) Interview with an outside source did not have any concerns. A review of records revealed that residents had a schedule posted in their room with specific housekeeping days that included contact numbers to their front desk area. In addition, on the bottom of the page of a posting on the residents’ wall was a bolded remark with many asterisk symbols that said to push their call button for assistance. Additionally, the memory care and assisted living care staff have a laundry schedule for each of their three shifts. The Care Staff Assignment sheet showed that staff signed responsibility for completing the tasks to their assigned unit(s) daily. On November 2, 2023, LPA toured the facility and observed that the residents’ linens were cleaned and in good repair. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not maintain residents records current with updated medical records in the residents’ files, specifically resident #1 (R1) and resident #2 (R2). A review of records revealed that the facility maintained a facility file for all residents. Medical records for R1 were current under their hospice binder. In review of R1’s file revealed that responsible party information was located within the file documents and the medical documents were current. A review of R2’s records revealed that their medical information, specifically their Physician’s Report (LIC602) was dated 7/5/22 and is in the process of obtaining a more current update report. A request dated 11/10/23 was sent to R2’s physician. Based on the information obtained, there is insufficient evidence to support the allegation. It was specifically alleged that staff did not have sufficient training prior to working independently. Interviews with staff said they do provide training online and hands-on training with their staff. According to Enliven Director, the facility provided training to their new employees upon hire. Depending on the experience of the new employee hire, they will provide them with their onboarding, online training, and have them shadow another staff, then release them for independent duties. Per Enliven Director, training ranged from 5 days of training for an experienced employee to three weeks for an employee to feel comfortable enough to be released to work independently. Per the Enliven Director, if staff still have questions they are able to ask co-workers after they are independently released. A review of staff training records revealed that the facility provided training to their staff upon hire. New employees completed training modules through either the facility’s internal training system (“classroom”) or hands-on (“shadowing”). Each training sheet was specific for each staff by their position of hire. Based on the information obtained, there is not enough evidence to support the allegation. (Continue on LIC9099-C) Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff, residents’ and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director David Armour and Perla Provencal, Director of Assisted Living . A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Armour at the conclusion of the visit. The signature below confirms the receipt of these documents.