Interviews conducted with Staff Members S1, S2, S3 and S4 indicated that care is being provided adequately to all residents in care. It was indicated that staffing is increasing and overall care is easier to manage with the current number of staff. S1, S2, and S3 indicated that they would like one more staff on the floor for the morning AM shift but are able to still complete all tasks assigned. Records reviewed indicated that there are staff on each shift to assist the residents in care and staff schedule indicates an increase in staff over the last few months. Therefore, the allegation inadequate staffing to provide care is unsubstantiated.

Emergency pull cords not functioning

Interview with Executive Director (ED) indicated that a family member had informed her that there were several pull cords not working properly. ED immediately took action and had the maintenance team change all batteries in all pull cord devices in the facility. Multiple tests have been conducted on the pull cord system which indicated that all pull cord devices are working properly. Although the pull cord system might have not been working properly, when it was brought to the attention of the ED, it was quickly addressed and all pull cord devices were accessed. Therefore, the allegation emergency pull cords not functioning is unsubstantiated.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

Interviews conducted with staff members S1, S2, S3 and S4 indicated that medications are being given as directed per physician’s orders. Med techs are careful to ensure proper medication distribution to the residents in care. Records reviewed of resident medication administration records (MAR) shows that medications are being given correctly and are documented properly to avoid error. Therefore, the allegation medications are not given as directed is unfounded.

Not reporting incidents

Records review of multiple resident files indicated that staff document in daily progress notes when family is contacted and the reason for contact. Staff inform resident’s responsible party of any incidents or concerns that arise while at the facility. Facility staff also inform licensing and the Ombudsman of any concerns or incidents that occur. Therefore, the allegation not reporting incidents is unfounded.

Staff not following activities calendar

Interviews conducted indicated that the facility utilizes a program called “The Moment Program” which allows the facility to pivot their activities schedule based on the residents abilities. The program is flexible and supports individualized care and resident choices. Observations indicated that staff were assisting residents with activities, residents were also participating in watching a movie, and staff were heard asking residents what activity they would like to participate in at that time. Therefore, the allegation staff are not following activity schedule is unfounded.

Inadequate hygiene supplies for residents in care

Interviews conducted indicated that there is an adequate supply of hygiene supplies available to staff at the facility. Observations indicated that each of the three supply closets had a large stock of hygiene supplies with different sizes available. There were also hygiene supplies in resident rooms available for staff and resident use. Therefore, the allegation lack of hygiene supplies in unfounded.

Continued on 9099C2 page

Interviews with Staff members S1, S2, S3 and S4 indicated that staff given residents showering at least two times a week with additional showers as needed. Staff follow a shower schedule and document on the online system and paper shower sheet to indicate that a shower was provided, if there are any skin issues and if there is any concerns that need to be noted. S1, S2, S3 and S4 indicated that staff will attempt to change face or request assistance from a later shift if the resident refuses a shower, which happens occasionally. Records review indicated that staff are filling out shower forms and indicating whether a shower was provided and if any concerns came up. Therefore, the allegation showers not being given to residents is unfounded.

Volunteers not fingerprint cleared

Records reviewed indicated that there are no volunteers at the facility at this time. Review of staff roster and staff files indicated that all personnel that work at the facility are actual staff and not volunteers. Interviews conducted indicated that there are only qualified staff at the facility and no volunteers although sometime family members of residents will come in and sit with the residents in common areas. Therefore, the allegation volunteers are not fingerprint cleared is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.