Complaint Investigation Report

Allegation: Staff does not respond to resident’s pendant call.

It was alleged that the facility staff do not respond to residents' pendant and emergency pull cords. To investigate this allegation, LPAs conducted a random inspection of two (2) pendants and three (3) emergency pull cords in the bathrooms. The facility’s expectation for response time is 10-15 minutes. However, during the inspection only one (1) pendant call was received by the facility and a caregiver responded to the call in seventeen (17) minutes. Moreover, at 2:36pm, LPAs along with the Executive Director tested residents' pendant and emergency cord in room #153 and waited until 2:56pm. No staff showed up to reset the call buttons. Based on LPA's observation and review of the information received, this allegation is Substantiated .

Allegation: Staff not maintaining resident’s hygiene.

It was alleged that on 03/31/24 R1 came back from the hospital/rehabilitation and was not given a shower since the facility had no shower chair. To investigate this allegation, LPAs conducted interviews with the Executive Director, two (2) MedTechs and one (1) out of two (2) staff members. Interview with the Executive Director and facility staff revealed that R1's family was requested to purchase/provide a shower chair, which was delivered on 04/15/24. Although the shower chair was already delivered/received, it was not assembled until 04/16/24. Moreover, LPAs conducted review of the facility shower log and observed that R1 was scheduled to have a shower on 04/15/24, but no shower was provided to the present day. Therefore, based on interviews and record reviews this allegation is Substantiated.

Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.