complaint·June 16, 2023

(Continued from LIC9099) Records review did not show evidence that staffing numbers were inadequate to meet the basic needs of residents and/or to assist with their requests. On 3 unannounced facility visits LPA directly observed caregivers assisting residents with Activities of Daily Living (ADLs), medication, activities, and using walkie talkies to communicate with other staff. Regarding the allegation, "Staff were not properly trained", staff interviews revealed that 40 hours of training is provided during onboarding that includes both online classes, shadowing, and hands-on practice. Staff receive an additional 3 hours of online training each month and various in-service trainings facilitated by management staff that are situation-specific to the needs of the facility. Interviewed staff advised feeling competent in their job duties and consistently identified facility protocols regarding the various responsibilities performed for their role. Outside source interview did not give evidence to any issues regarding staff training and/or care of residents. Records review revealed that staff had received both online and in-service training on caring for the population this facility serves. On 3 unannounced facility visits LPA observed staff assisting residents with Activities of Daily Living (ADLs), medication assistance, activities, and emergency situations. LPA did not observe any staff performing a task in a way that indicated lack of competency or training. Regarding the allegation, "Facility is in disrepair", it was alleged that staff were having to use a broken sink with buckets of water to care for residents. Staff interview revealed that the facility had an ongoing remodel that was completed in October 2022 and the remodeled facility wings were inaccessible to residents and staff during the time of repair. Staff interview revealed that one kitchen sink in one wing temporarily had a leak that was being fixed, requiring a bucket to catch water droplets. Staff interview confirmed that at no time buckets of water were being used to care for residents, and residents did not have access to the sink in question at any time. Outside source interview did not corroborate the allegation that staff were caring for residents from a broken sink. Records review did not give evidence to the allegation that staff were having to use a broken sink to care for residents. On 3 unannounced facility visits LPA did not observe any sink in the facility to be in disrepair or any buckets of water identified for resident care. Regarding the allegation, "Facility did not ensure resident(s) had access to personal care supplies", it was alleged that the facility did not consistently provide personal care items for residents. Staff interview revealed that the facility provides all personal care supplies to residents at no cost. (Continued on LIC9099-C) (Continued from LIC9099-C) The facility provides shampoo, conditioner, soap, toothbrushes, toothpaste, and skin care items; however families can purchase and request the facility to use a preferred item of their choice for a resident. Showering protocol is for staff to obtain the personal care products from the storage room prior to showering residents. Staff interview revealed that the facility maintains an overflow of personal care supplies at all times. Outside source interview did not corroborate the allegation that the facility was not maintaining personal care supplies for residents. During an unannounced facility visit LPA directly observed the storage room stocked with personal care supplies and did not observe it to have missing items or an amount inadequate to meet the personal care needs of residents. 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 UNSUBSTANTIATED. An exit interview was conducted with Janelle Harris, Business Office Manager, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.