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32 | On today’s visit, LPA issued the superseded licensing report and re-delivered the licensing report. The findings will remain the same.
Regarding allegation: Staff inappropriately entered resident's room without permission.
It is alleged that staff entered resident’s room at night without resident’s invitation or permission. The investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training. The investigation revealed the following: On 11/15/2025, R1 pendant malfunctioned and staff took R1’s pendant for repair. S9 stated that S9 on 11/15/2025, around 10:30 PM, S9 was asked by facility shift nurse to return emergency call pendant to R1 at the beginning of S9’s shift. R1 is an independent resident, therefore, S9 does not normally enter R1’s room. S9 knocked on R1’s door two times to announce S9’s presence to R1, before entering R1’s room. S9 stated that S9 did not ring R1’s doorbell in case that R1 was already asleep. Upon S9 entering R1s room, R1 awoke and was startled and in distress after seeing an unknown staff member (S9), had entered R1’s room. R1 was aware that staff would return R1s pendant, however, R1 reported not being aware that staff would return R1s pendant on the same night the pendant was taken for repair. Interviews with residents revealed that nine (9) out of ten (10) residents stated that residents are not aware of staff entering residents’ rooms without permission. Six (6) out of ten (10) residents stated that staff sometimes wake residents at night to do welfare checks, but residents stated that residents understand the reason for staff doing welfare checks at night. Interviews with staff revealed that nine (9) out of nine (9) staff stated not to be aware of staff entering residents’ rooms without permission. Staff always knock on the door or ring the doorbell before entering residents’ rooms and staff announce themselves. At night, some residents may wake up during welfare checks, but staff try not to wake up residents. LPAs document review revealed that the facility has provided staff training on proper room entry on 11/17/2025, and 01/05/2026-01/12/2026. Based upon the investigation, client and staff interviews, document review, and LPA observations, there is no preponderance evidence to show that staff enters residents’ rooms without permission.
Regarding allegation: Staff inappropriately woke resident up.
It is alleged that staff entered residents’ room at night without the residents invitation or permission, causing the resident to wake up startled and become distressed when staff shone a light on the residents’ face. The investigation consisted of physical plant tours, interviews with staff, residents, and review of R1 facility file, including admission agreement, physicians report, needs and service plan, and facility staff training.
(Report continues on page LIC-9099C...) |