Complaint·March 27, 2025

The allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” alleges that the facility did not have functioning auditory alarms or adequate staff supervision to prevent resident #1 (R1) from leaving the facility unassisted. During the initial complaint investigation on 01/22/2025 LPA Cortez observed the front door and the sliding glass door of the front living room to be equipped with auditory alarms. LPA observed these alarms to be non-functional when the doors were opened. Facility staff informed LPA that the alarms worked but were turned off. During today’s visit LPA Byrne observed the kitchen side door, the sliding glass door of the front living room, and the hallway sliding glass door to be equipped with auditory alarms that were in the off position. All three (3) Auditory alarms failed to alert when the doors were opened. LPA asked staff why the alarms were turned off, staff were unsure but believe that it may have been because of the gardeners working. Additionally, in the month of December R1 eloped from the facility grounds without the notification of an auditory alarm. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” Therefore, the allegation is deemed Substantiated at this time. The allegation of “Staff did not answer resident's call button in a timely manner.” alleges that the facility staff did not answer R1’s call button in a timely manner. During interviews with residents, two (2) residents stated that staff have been slow/unresponsive in the past to their calls for assistance. Resident #2 (R2) stated that facility staff have silenced their call button before after attempts to notify staff that they need assistance. LPA pressed the call button for R2 during the interview at 10:56 AM. At the time of the button press LPA attempted to listen for a chime but was unable to hear any notification that a call button was pressed. LPA waited 15 minutes until 11:11 AM and no staff responded to the call button press. LPA asked S1 for the reason the call button was not answered. S1 stated that they must have not heard the notification and denied that resident call buttons are ever silenced. At approximately 12:50 PM LPA asked staff #2 (S2) to press the resident’s call button. When this button was pressed LPA observed the alarm to go off. S2 confirmed that R1, while they resided at the facility, had a call button to notify staff that they required assistance. Staff denied ever missing a call button notification and S1 reiterated that their average response time to resident’s requests for assistance does not exceed seven (7) minutes. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not answer resident's call button in a timely manner.” Therefore, the allegation is deemed Substantiated at this time. Continued on LIC 9099C. The allegation of “Staff did not ensure resident's showering needs were being met.” alleges that the facility staff were not showering R1 on an appropriate basis. Interviews with two (2) residents revealed that they feel like facility staff are not showering/bathing them enough. One (1) resident stated that they have asked staff for a shower previously and were told that staff would do it later in the day. The resident stated that staff “Blew them off” and never returned to shower them. One (1) resident interviewed stated that they had gone a month without a shower. LPA interviewed staff members who stated that resident’s showers are on a schedule and are given 2-3 times per week. Both staff interviewed denied skipping resident’s showers unless the resident refused. S2 stated that some residents have refused showers this month and it is logged in the shower binder. LPA observed the shower log for the month of March. LPA observed one resident to have a shower that was not given according to the schedule. One resident confirmed that they had not been getting showers on the dates that were logged in the binder. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff did not ensure resident's showering needs were being met.” Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were cited (refer to LIC 9099D). The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report and appeal rights were provided. The allegation of “Staff did not follow medical directions for resident's medical needs.” alleges that the facility staff did not follow medical directions prior to a uranalysis appointment for R1 and that facility staff did not assist in the proper storage of a urinalysis sample. LPA interviewed S1 who recalled the incident with R1’s urine sample. S1 stated that R1 had utilized the restroom prior to their scheduled urinalysis appointment. LPA interviewed Witness #1 (W1) who corroborated this statement. As R1 was unable to urinate at the time of their appointment they were given a sample collection cup to submit at a later date. S1 stated that they had R1 urinate in the sample cup the next day but the staff member assisting R1 got distracted by a call from another resident and left the sample on the counter of the bathroom. S1 stated that R1 took the cup and poured the sample into the toilet. W1 stated that they arrived to the facility to take R1 to drop off the sample and staff were trying to have R1 produce another sample. W1 stated that they told staff to take care of submitting the sample and did not believe R1 would pour out the sample. LPA confirmed with S1 and W1 that a sample was submitted to the lab the same day. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not follow medical directions for resident's medical needs.” Therefore, the allegation is deemed Unsubstantiated at this time The allegation of “Staff did not provide resident adequate food meals.” alleges that the facility staff did not provide R1 with nutritious meals. Interviews with three (3) residents revealed that the facility serves enough food to the residents in care. Interviews with staff revealed that the facility offers a variety of foods to residents and accommodations are made if residents do not want what is being served. LPA observed the facility to have adequate amounts and variety of foods to be served to residents. LPA observed the portions of food being served to residents at 01:47 PM and observed the portions to be adequate. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide resident adequate food meals.” Therefore, the allegation is deemed Unsubstantiated at this time. The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report was provided.