complaint·January 20, 2023

On the allegation: Staff do not respond to resident's call light in a timely manner. LPA reviewed the call light/pendant records for R1, LPA found during the dates of 03/09/2022 to 04/05/2022. R1 had a total of 27 calls. 8 calls were over 10 minutes. The dates and length of those calls were 03/09/2022 for 10 minutes 31 seconds (10:31), 03/09/2022 for 15:48, 03/09/2022 for 35:18, 03/10/2022 for 12:04, 03/11/2022 for 41:13, 03/28/2022 for 10:27, 04/01/2022 for 29:36, and on 04/03/2022 for 40:36. Staff interviewed were not able to recall why those calls were not acknowledged or cleared timely. Staff interviews stated sometimes the call light/pendants were not working properly and/or if you walk-in on an emergency you need take care of that first then clear the call light/pendant after you helped the resident. Staff interviewed stated the facility was experiencing outbreaks of Covid, Outbreak of norovirus and were short staffed when the facility had call offs during this time. Interview with witness stated that R1 complained the call pendant was not being answered. Based on the evidence the allegation is deemed Substantiated at this time On the allegation: Staff did not have an Oxygen sign on the resident’s door. LPA Olson observed 1 resident room without an oxygen sign on the door. Witness stated they did not see an oxygen sign on the door when they were present at the facility. Staff stated they do have oxygen signs on the resident’s doors but there is one resident that takes the signs down. Staff stated they are now hanging the sign higher up so it cannot be taken down so easily. Based on the evidence the allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator. On the allegation: Staff do not wear masks properly. LPA’s interviewed staff, residents and witness which revealed that all staff wear masks properly at the facility all the time. Masks are provided at entry of facility to all staff and visitors entering. LPA Olson observed masks being worn by all staff. LPA De Leon observed staff wearing masks. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not following COVID guidelines. LPA Olson conducted a visit and upon arrival she was screened for Covid-19 by front desk staff prior to entry into the facility, staff were wearing masks properly and signs for covid-19 were hung in the common areas. Residents stated the facility is cleaned and wiped down regularly. Staff stated the facility was cleaned and disinfected regularly, masks were mandatory, and everyone was following Covi-19 guidelines. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time. On the allegation: Resident left in soiled diapers for an extended amount of time. LPA interviewed staff which revealed R1 was not on a care plan for incontinence care when R1 moved into the facility. R1 took care of R1’s own needs with little to no assistance. Staff completed rounds every 2 hours R1 had a change in condition in the beginning of April 2022 at which time R1 needed additional help with R1’s incontinent needs and briefs were necessary. R1 became bed bond on hospice services and went to 1-hour checks at that time. Hospice records recorded 1 incident of the resident being wet on hospice visit but no timeline was given to state this had been for an extended amount of time. R1’s medical records do not state any rashes or sores were present. Based on the lack of evidence this allegation is Unsubstantiated at this time. On the allegation: Resident's rooms are dirty. LPA interviewed staff, residents, and witness which revealed the facility was clean, the rooms were cleaned regularly by caregivers and housekeeping staff and the linens were changed weekly or more if needed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Resident left on the floor for an extended amount of time. LPA interviewed staff, residents and witness which did not reveal anyone being left on the floor for an extended amount of time. Staff stated they do 2-hour checks for most Assisted Living residents some residents can be every hour and every 30 minutes due to being ill, declining health, hospice or being a fall risk. The staff stated the residents have a pendant to push if help is needed before the regular rounds are done. Staff stated they do not remember R1 being on the floor for an extended amount of time. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not properly trained to work with residents. LPA interviewed Staff, Residents and witness which revealed the staff providing care to the residents do a good job and are trained properly on resident care. Staff training records reviewed; staff are meeting the training regulations. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the Administrator.