In regards to the allegation: “Staff did not meet resident's diapering needs in a timely manner.” It is alleged that a staff is usually left alone to care for 40 residents and residents had to be in soiled diapers for a long time because staff would be busy giving showers to other residents. Interviewed staff denied the allegation and stated that they have adequate staffing at this time. Staff stated that they do rounds every 2-3 hours per shift not only to change diapers for incontinent residents, but to check if residents are doing well or need other assistance. Documents reviewed indicated that there are 11 Caregivers on rotated schedules and 2 on call Caregivers staff. Document also showed 2 caregivers on duty per shift. S1 stated that if additional help is needed, she also helps and other staff like Housekeepers, Med Tech, Activities Director and Receptionist can also assist as they are all cross trained. Staff stated that there are 2-3 caregivers per shift, and a caregiver is assigned between 10-15 residents per shift, so the level of care are balanced and not one staff carries a heavy load. None of the staff interviewed complained about being overworked due to short staffing. 10 out of 10 residents interviewed denied the allegation. 5 out of 10 incontinent residents who were interviewed stated that staff assist them all the time in diaper changing and never left them in soiled diapers. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation.

In regards to the allegation: “Hot water is not made available to residents in care.” It is alleged that the hot water for the residents is turned off and only turn it back on when licensing visits the facility. Interviewed staff denied the allegation that hot water is only turned on when licensing visits the facility. S1 stated that with their new hot water system, hot water is automatically shut down at midnight, and turn back on about 3am or 4am when no one is using it. 7 out of 7 staff interviewed stated that hot water is always available when they use it, and no one has complained about hot water issues lately. 10 out of 10 interviewed residents stated that hot water is available for their use all the time. Residents interviewed indicated that they do not have any issues or concerns with hot water. During the initial visit on 01/04/2024, LPA conducted water temperature check on random residents’ rooms in the 1st and 2nd floors (Rooms: #3, #7, #12, #13, #17, #51, #56, #59, #64 and #81). The hot water temperature measured within 105-120 deg. F which is within Title 22 regulations requirement. LPA also reviewed facility records indicating that the tankless water system was last serviced for cleaning and adjustment of water temperature in the kitchen on 09/08/2023. Documentation reviewed and interviews conducted do not corroborate this allegation.

In regards to the allegation: “Facility elevator is in disrepair.” It is alleged that the facility elevator is malfunctioning, and residents keep getting stuck in the elevator. It is also alleged that staff can pry open the elevator doors and help the residents to open the elevator. Interviewed staff denied the allegation and none of the staff know of anyone being stuck in the elevator. S1 stated that the elevator was not broken, but it is serviced monthly. Staff indicated that while elevator is being serviced, it will be out of service for approximately 30 minutes. Staff stated that residents are notified in writing and signs are posted in the common areas, including the elevator. Staff indicated that they also make an announcement prior to the elevator being out of service so residents have enough time to go up and down their rooms. 10 out of 10 residents interviewed stated that they never heard anyone being stuck in the elevator. Residents indicated that they hear the announcement if elevator is going to be out of service and have no issues with that. Residents also indicated that maintenance staff are quick to reset the elevator again, no more than half hour. LPA tested the elevator twice during the initial and subsequent visits and found that the elevator was operating properly at both times. Residents were also observed using the elevator. LPA reviewed documentation from E.K. Elevator Co. which indicated they visited the facility on 12/03/2023 for maintenance and the elevator was operating properly. Therefore, there is insufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with staff, residents, review of facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held and a copy of this report was provided to Ana Y. Giron, Administrator.