On February 12, 2025, LPA Domingo observed a bulletin that informed the residents and family regarding a resident council meeting located near the lobby of the facility on a television screen.

Outside Source 1 (OS1) was interviewed and they were aware of a resident council meeting. OS1 stated that there is a calendar that has the resident council meetings posted. OS1 stated that there are also bulletin boards with the date and time in the facility.

During an interview with Outside Source 2 (OS2), they stated that they were aware of a resident council meeting.

Outside source 3 (OS3) interviewed, and they were aware of a resident council meeting because they viewed the facility calendar, which has the resident council meeting posted.

During an interview with Staff 1 (S1), S1 revealed that there were calendars with the resident council date and time of the meetings.

Staff 2 (S2) was interviewed, and they stated that there is an appointed designated staff liaison responsible for aiding the resident council, and that is usually the activities director. S2 also stated that the resident council meetings were posted on the facility calendar, and there is a bulletin that has the resident council meetings.

During an interview with Staff 3 (S3), they stated that there was a staff liaison for the resident council meetings but at times they are asked to step out of the meeting and the staff liaison steps out of the meeting out of respect but is readily available when the resident council requests any assistance.

It was alleged that the facility did not assign a designated staff liaison to aid the family council. OS2 was interviewed and stated they were not sure of a designated staff liaison to aid with the resident council, but they do know that a staff member assists the resident council with a room to meet in and any supplies needed for the meeting. OS2 stated that they were sure the facility staff provided a room for the residents to meet, and that meant that the staff were the liaison.

Records were reviewed and Resident 1’s (R1’s) records were not updated with the resident council meetings that started on July 14, 2024. Records reviewed of three newly admitted residents, Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) and there was not any up dated information shared with the residents or their designee regarding the newly established family council meetings or of a designated staff liaison to aid the resident council.

During an interview with Resident 2 (R2) and Resident 3 (R3) they stated that they were aware of the resident council meetings by word of mouth, but they were not aware of any information by any other means, R2 and R3 were unaware of a designated a staff liaison to aid the resident council.

It was alleged that the facility did not accord resident dignity in their relationship with staff. Regarding the allegation that the facility did not accord resident dignity in their relationship with staff, interviews with residents revealed the staff accorded them with dignity and respect. None of the residents reported being spoken to or overhearing other staff speak in different languages. The residents stated that they feel the staff can speak in any language when they are on a break or leaving the facility. The residents did not state that the staff speak in a different language when assisting them.

Interviews with outside sources who frequent the facility did not report any concerns with the facility not according to residents with dignity in their relationship with the staff.

Lastly it was alleged that the facility did not accord safe, healthful and comfortable accommodations. Regarding the allegation that staff the facility staff did not accord safe, healthful and comfortable accommodations. Interviews with residents revealed them feeling their call lights were being answered in a timely manner and staff follow the wake-up schedule in the morning.

Records reviewed showed that the pendant alert system for the residents were answered with no complaints. The residents stated that most of the time the staff will let the residents know if they are behind schedule. The resident's interviewed stated that they appreciate the staff communicating when there will be a little bit of a wait. Usually, another staff will assist as needed so there are no concerns.

Staff corroborated the wake-up times that are requested and verified that if they will be later than scheduled, they will inform the resident or have another staff assist them.

LPA observations of various rooms during unannounced facility visits did not raise any concerns regarding the call light response time or the residents' wake up schedule in the morning.

The department has investigated the complaint alleging the resident council rights are not posted in a prominent place at the facility. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Aileen Spence Associate Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.