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32 | Regarding the allegation: Staff did not ensure the residents had running water. It is being alleged that resident #1 (R1) had no water. During LPA’s interview with R1, “they stated that they did not have running water for the weekend of 03/07/26-03/08/26 and could not take a shower.” During LPA’s physical tour on 03/10/26, LPA tested the water in R1’s bathroom and R1 had water in the shower area but not the sink/handwashing area. Also, LPA received an Unusual Incident report on 03/06/26, stating that water was going to be shut off for about thirty (30)-sixty (60) minutes but not for the entire weekend. LPA interviewed an additional fifteen (15) residents that confirmed they did not have water that weekend. LPA interviewed three (3) staff that confirmed there was no water that weekend. Therefore, based on the observation and interviews conducted, the allegation is SUBSTANTIATED at this time.
Regarding the allegation: Staff did not respond to a resident's call button in a timely manner resulting in not meeting resident's medical needs. It is being alleged that resident #1 (R1) fell, used their emergency call button, and nobody came to help them, leaving R1 on the floor for hours. During LPA's interview with R1, R1 stated, "they were left on the floor for several hours because no staff responded when they pressed their pendant." During LPA’s physical tour on 03/10/26, LPA pressed the emergency call button in R1’s bathroom and no one responded. In addition, LPA pressed R1’s pendant and no staff responded. As a result, it was determined that R1's pendant and call button were not working and that was the reason for not meeting R1's medical needs. LPA interviewed three (3) caregivers that confirmed it depends how many resident's they have to care for, what they need and them communicating to another caregiver if they are currently busy prolongs the time to respond to the call buttons. Although, LPA interviewed an additional fifteen (15) residents that confirmed their pendants and call buttons work because they use it and staff respond to them the allegation is still substantiated based on R1's malfunction of equipment in their room. Therefore, based on LPA's observation of R1's pendant and call button not functioning and interviews conducted, the allegation is SUBSTANTIATED at this time.
An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director.
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