Complaint·February 24, 2025

During the complaint visit, LPA observed R1's toilet to be in good working condition. Based on interview conducted with R1, the facility replaced his/her toilet with a new toilet. According to the administrator, the facility was having plumbing issues throughout the facility, however it has been fixed as all the toilets are in good working condition. Regarding the allegation, facility does not meet residents' nutritional needs, according to the reporting party, the facility's food quantity and quality are not adequate to meed the nutritional needs of the residents and the facility does not give the residents enough food to meet those nutritional needs. In addition, the reporting party indicated, the facility sometimes runs out of food. During the investigation, LPA interviewed residents, observed the facility's food menu and observed the facility's food supply. LPA observed 2 day perishables and 7 day non-perishables present at the facility. LPA observed one weeks food menu and observed that the facility provides several entree options each meal with additional daily items and snacks to choose from. Kitchen staff have record of resident dietary restrictions with notation of restrictions labeled on the menu for each individuals' diet. Upon interviews with residents, LPA received inconsistent information regarding food taste but was found that the facility provides 3 meals a day with a variety of nutritious food options. Regarding the allegation, staffing levels do not meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents by not responding to residents timely and providing the actual services when appropriate. During the investigation, LPA reviewed staff schedule, 5 residents response times. According to the administrator, there are 6 caregivers for 70 residents during the morning and afternoon shift, 11 of which are independent resident. LPA reviewed 5 residents call buttons within the last months, and on average the response time is 7 minutes. Regarding the allegation, staff are not trained to meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents and the staff are not trained properly to meet those needs by not responding to residents timely and providing the actual services when appropriate. (Cont to 9099C). During the visit, LPA reviewed 5 staff files and observed training records. Staff records are complete, with training logs that have met the basic requirement. On going staff training is provided monthly regarding the following topics; infection control, proper transferring, incontinence care, skin checks, first-aid, etc. Regarding the allegation, facility is not notifying residents and families of changes taking place in licensee or corporate structure, according to the reporting party, there are changes being made on the corporate level, or ownership level, and those changes are not being communicated to residents and the families of the residents. During the investigation, LPA interviewed responsible parties, administrator, business office manager, and reviewed documents. The administrator and the business office manager denied this allegation and indicated that a letter was sent to residents and family members on October 1, 2024 notifying them that there will be a change in management company. Administrator provided LPA a copy of the letter for review. According to residents interviewed, it was indicated that they did receive letters from the facility notifying them of the change of management. Based on observations, documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.