It is alleged that staff do not provide adequate supervision, resulting in residents sustaining multiple falls. During staff interviews, staff reported that residents who are at risk for falls receive supervision based on their individual needs. Staff stated that residents requiring increased assistance due to mobility limitations or changes in condition receive additional supervision. Staff further reported that residents identified as being at risk of getting out of bed unassisted have bed sensor alarms in place to alert staff when the resident attempts to get out of bed, allowing staff to respond promptly. Staff also reported that residents are assessed following a fall, and appropriate action is taken based on the resident's condition. While one staff member reported that there had previously been only one caregiver assigned during some night shifts, staff generally reported that current staffing levels are sufficient to meet residents' supervision needs. During the facility walkthrough, the LPA observed bed sensor alarms installed on the beds of residents identified as being at risk for falls or attempting to get out of bed unassisted. During resident interviews, residents reported feeling safe and stated that staff provide assistance when needed. Residents did not express concerns regarding staff supervision or report that inadequate supervision contributed to falls.

It was alleged that staff do not seek medical attention for residents in a timely manner. During staff interviews, staff reported that residents are assessed immediately following a fall or medical incident and that 911 is called when a resident requires emergency medical attention. Staff stated they have not been instructed to delay or avoid seeking medical care. Review of the facility's Medical Emergency Procedures confirmed that staff are instructed to call 911 when appropriate and notify the administrator and the resident's responsible party. During resident interviews, residents reported that staff respond promptly when assistance is needed and did not express concerns regarding delays in receiving medical attention.

Allegation: Staff does not ensure incidents are being reported.

It was alleged that staff do not ensure resident incidents are properly documented and reported to responsible parties. During staff interviews, staff reported that resident incidents are communicated to the Administrator and documented in the facility's electronic charting system and staff communication logs. Staff stated that the administrator is generally responsible for notifying responsible parties and Licensing, and that responsible parties are contacted following resident incidents or changes in condition. Staff also reported that they may contact family members directly when concerns arise. No staff reported being aware of incidents that were intentionally left undocumented or unreported. During record review, Administrator provided documentation demonstrating that incident reports had been submitted to Licensing and responsible parties were notified.

(continued on 9099C)

It is alleged that staff do not ensure residents' showering and personal hygiene needs are being met. During staff interviews, staff reported that residents who require assistance with bathing receive showers according to their individualized schedules, while residents who are independent shower on their own. Staff stated that bathing assistance and resident refusals are documented in the facility's electronic charting system. Staff consistently reported that staffing levels have not prevented residents from receiving showers as scheduled, although some residents occasionally refuse bathing. During resident interviews, residents generally reported that their personal care and hygiene needs are being met. Residents indicated that they receive assistance from staff when needed and expressed satisfaction with the care provided. Residents who required assistance with bathing reported that staff provide support, while residents who are independent stated that they manage their own personal hygiene. Residents interviewed did not express concerns regarding access to showers, bathing assistance, or personal hygiene care. Several residents stated that they feel well cared for and supported by staff.

Allegation: Staff does not ensure facility has adequate food supply.

It was alleged that staff do not ensure the facility maintains an adequate food supply to meet residents' needs. During staff interviews, staff generally reported that the facility maintains an adequate food supply. Staff stated that groceries are purchased regularly and replenished when supplies run low. Staff also reported that if a specific food item is unavailable, substitute items are provided. One staff member expressed concerns that certain perishable items were occasionally unavailable. During resident interviews, residents generally reported that they receive enough food and did not express concerns regarding food availability. One resident stated that food supplies occasionally become low; however, food remained available and substitute items were provided. During the facility walkthrough, LPA observed an adequate supply of refrigerated, frozen, canned, and dry food items available for resident use.

Allegations: Staff does not ensure facility has adequate cleaning supplies and Staff does not ensure resident has adequate diaper supplies.

It was alleged that staff do not ensure the facility maintains an adequate supply of cleaning products necessary to maintain a sanitary environment. It was further alleged that staff do not ensure residents have an adequate supply of incontinent products, including diapers, as needed. During staff interviews, staff consistently reported that the facility maintains adequate cleaning supplies and incontinence products. Staff stated that supplies are monitored, and the administrator is notified when items begin to run low so they can be reordered. Staff reported that they have not observed the facility run out of cleaning supplies or diapers. (continued on 9099C)

Although supplies may occasionally become low, they are replenished promptly. Staff also stated that residents who require incontinent products receive the necessary supplies, and some family members occasionally provide additional personal items for their relatives. During the facility walkthrough, LPA observed an adequate supply of cleaning products throughout the facility. LPA also observed plenty of diapers and other incontinence products available for residents. Overall, the facility maintained sufficient resident care supplies to meet residents' needs at the time of the visit.

Allegation: Staff are utilizing video surveillance cameras with audio.

During staff interviews, staff reported that surveillance cameras are located throughout the facility, including common areas such as the living room, kitchen, hallways, and exterior areas. Some staff believed the cameras had audio recording capabilities, while others were unsure whether audio was being recorded. Staff reported that the facility utilizes Ring cameras and stated that the audio function has been turned off. Staff indicated that the cameras are primarily used to monitor common areas and promote resident safety. LPA's investigation did not reveal evidence that the facility's surveillance cameras were actively recording audio.

Based on the investigation conducted, which included interviews with staff and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegations. Although the allegations may have happened or is 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 was held, and a copy of this report was provided.