LPA observed the floors in R1's room and floors on the 3^rd floor and noted the following: R1’s room floors have an incline to a degree from sink to patio door and in bathroom. The areas in common walkway and near the elevator have an unevenness and is more apparent when R1 is using walker to ambulate over the areas and when individuals with wheelchairs are entering the elevator. LPA briefly discussed the floors with Staff #2 (S2) who mentioned the cost would be significant to have the floors leveled.

Based on interviews and observation there is information to verify the allegation. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Deficiency cited on 9099D

Exit interview conducted/Appeals Rights /Copy of report printed

Additionally, R1 was informed that emergencies services can be called for their own care, but staff should be contacted first in order to assess residents and verify if 911 services are needed. The executive director also revealed that staff do not prevent 911 calls from being made and would never threaten a resident, nor have they threatened R1 with any eviction notice for doing so. Interview with R1 it was revealed that a resident was having a medical emergency and therefore R1 contacted 911. R1 was not available to provide reason for not alerting staff but noted it is their right to contact 911. LPA asked R1 if they recalled speaking with the executive director regarding contacting 911 services and R1 states wasn’t clear what was said and requested to go to the executive director’s office. While in the executive director's office R1 asked if they were able to contact 911 and the executive director reiterated that R1 can call for self but need to contact staff for other residents. R1 noted their understanding by nodding head and saying ok.

Based on the information received during the investigation, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Staff yelled at a resident

LPA interview with executive director and staff revealed the following: executive director refutes this allegation, revealing has not received any notice from R1 regarding yelling or mistreatment from any staff and that staff maintain a professional demeanor and has not heard or witnessed any staff yelling at any residents in care. LPA conducted interview with R1 who revealed that the staff that yelled at them worked at the facility in 2024 but no longer works at the facility, and does not recall when the left. LPA interviews six (6) out of seven (7) residents revealed they have not witnessed any staff yelling at R1 or any residents in care and staff has not yelled at them.

Staff do not ensure resident receive their mail

Staff do not ensure resident have access to their personal records

In regard to these two allegations: It was alleged that staff do not ensure residents receive their mail and staff do not ensure residents have access to their personal records. Interview with the executive director revealed the following: when mall is delivered by post office, the mail is held at the front desk, the residents are notified by concierge/front desk and residents stop by front desk and ask if they have mail.

The executive director deny they or any staff has withheld mail from R1 or any resident in care. The executive director also revealed that any request for records from residents must be written and should include what documents they are requesting such as admission agreements or copy of medical assessment and have not received a written request for records from R1.

Interview with R1 revealed that these issues are not a concern and would like to cancel or close these issues to focus on a big concern. R1 revealed they are receiving mail. R1 also revealed they wanted a copy of their medical file kept at the facility but was told to submit a written request. LPA informed R1 that if there is a rule/policy in place for a written request to receive the documents then R1 will need to follow that rule or policy.

Based on the information received during the investigation, there is not enough information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.