During resident interviews 5 of 5 residents stated that staff treats them with dignity, 4 of 5 residents stated that they do not feel intimidated by staff, 1 resident stated that sometimes they feel intimidated by staff. 5 of 5 residents stated that staff have not been verbally abusive to them.

During staff interviews 5 of 7 staff stated they had never witnessed or heard of any facility staff not treating residents with dignity, 2 staff stated they had witnessed or heard of facility staff not treating residents with dignity. 7 of 7 staff stated they had never witnessed or heard of any facility staff being verbally abusive to residents. 7 of 7 staff stated they had never witnessed or heard of any facility staff intimidating the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

Allegation: Staff are unable to communicate with residents.– UNSUBSTANTIATED.

During resident interviews 5 of 5 residents stated that staff are able to communicate with them properly and they can understand what staff are saying to them.

7 of 7 staff stated they were able to communicate with the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

Continued on LIC9099-C

During resident interviews 4 of 5 residents stated that their needs were being met, 1 resident stated that their needs were being sort of met.

6 of 7 staff stated there are enough staff to meet the resident’s needs, 1 staff stated there are not enough staff to meet the resident’s needs. 6 of 7 staff stated that all staff have the proper qualifications to do their job, 1 staff stated that not all staff have the proper qualifications to do their job.

Review of facility’s Staffing Requirements indicates that all staff are required to have the following documents in their personnel file: LIC501 Personnel Record, 9163 Request for Live Scan Service, LIC503 Health Screening Report-Facility Personnel, copy of Social Security card, copy of Photo ID. Med Techs are required to provide a First Aid and CPR Certificate.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

Allegation: Facility staff is restricting residents from receiving telephone calls. – UNSUBSTANTIATED.

During resident interviews 3 of 5 residents stated they are able to use the facility telephone to make and receive calls. 2 of 5 residents stated that they have their own mobile phones.

During staff interviews 3 of 7 staff stated that residents are allowed to receive telephone calls on the facility phone, 4 staff stated that residents are allowed to receive calls on the facility phone unless their POA says the resident cannot talk to the person who is calling.

Review of the facility’s Admission Agreement in the Personal Rights section includes that residents have the right “To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.” The Facility Policy on Telephone Calls document revealed that there are 6 phones which are located throughout the various hallways of the facility with 2 lines for the resident’s use.

Continued on LIC9099-C

During resident interviews 5 of 5 residents stated that staff keep their room clean and sanitary. 3 of 5 residents stated they have never had to clean their bathroom themselves, 2 residents stated they have to clean their bathroom occasionally.

During staff interviews 6 of 7 staff stated that resident bathrooms are cleaned every day. 1 staff stated they don’t know how often the resident bathrooms are cleaned. 7 of 7 staff stated that residents do not have to clean their own bathroom.

Review of the facility’s Admission Agreement revealed on page 9 that resident rooms are cleaned on a weekly basis. The facility’s Cleaning and Sanitation policy clarifies that deep cleaning is done weekly, all resident rooms and bathrooms are cleaned on a daily basis, and if there is an “accident” the room is cleaned and sanitized, and/or bedding changed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

Allegation: Facility staff are not documenting resident rate change appropriately. The facility is not following admission agreement. – UNSUBSTANTIATED

During staff interviews 5 of 7 staff stated if a resident requests a change of room they talk to the administrator. 2 of 7 staff stated they don’t know what happens when a resident requests a change of room. 5 of 7 staff stated if a resident has a room change, they don’t know if the resident is charged more for their new room. 1 staff stated if a resident has a room change, they are charged the same price. 1 staff stated that a resident is only charged more if they go from a shared room to a private room.

Continued on LIC9099-C

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was emailed to facility administrator Becky Baker for signature. Administrator agrees to sign, scan and email signed report back to LPA Knight by the end of the business day. No deficiencies were cited on today’s date.