Complaint·November 9, 2024

Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that the facility is not following COVID-19 protocols. Allegation were made that staff are not answering residents' call buttons in a timely manner. The investigation included a review of records and interviews with residents and staff. The records indicated that response times vary by situation, averaging between 22 seconds and 57 minutes after the call buttons are pressed. LPA Lee interviewed 6 out of 7 residents, none of whom expressed concerns about the timeliness of staff responses. Residents noted that staff make good efforts to answer calls promptly. Additionally, it was learned that care staff sometimes forget to clear the resident’s call pendant while attending to other needs. LPA Lee interviewed all 3 facility staff members, who denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that staff are not answering resident’s call buttons in a timely manner. Allegation were made that residents are not receiving their medications in a timely manner. The investigation included a review of records and interviews with residents and staff. LPA Lee reviewed the facility's eMAR Summary for August 2024, September 2024, and October 2024, which was complete. Additionally, LPA reviewed medications of 7 residents along with their corresponding eMARs and found no discrepancies. LPA Lee interviewed all 7 residents, none of whom expressed concerns about receiving their medications late. Furthermore, all 3 facility staff members denied the allegations. Based on the interviews and evidence gathered during the investigation, LPA Lee was unable to corroborate the allegation that residents are not receiving their medications in a timely manner. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. According to R1’s care plan, R1 is scheduled to receive one shower per week, every Wednesday. However, the records showed that R1 received: • August 2024: 2 showers • September 2024: 2 showers • October 2024: 1 shower This is below the required four showers per month as outlined in R1’s care plan. LPA Lee interviewed 6 out of 7 residents, all of whom stated they are receiving showers on time. Administrator Candi Bolin clarified that if no staff initials are recorded on a task log, it indicates that the assigned caregiver did not initials and it is unclear if R1 received showers; however, the Task logs indicated that R1 only received 1 to 2 shower for the month of August to October 2024. As a result, it was determined the facility was not meeting residents' hygiene needs. However, no additional notes were found to explain the lack of staff initials for R1’s showers; therefore, LPA Lee was able to corroborate the allegation that resident are not receiving showers in a timely manner. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.