Complaint Investigation Report

Allegation: Staff do not respond to resident calls for assistance.

The Department conducted interviews and file review regarding the allegation. Based on interview conducted with R1 on March 22, 2024, it revealed R1 likes the staff at the facility. R1 stated staff are helpful and responds to calls as needed. R1 stated R1 has a slight cognitive impairment but is sharp for the most part. Interview conducted with Executive Director on April 3, 2024 revealed the call system is an alert at the front receptionist desk, which indicates which room is in need for assistance which receptionist then call caregivers to the room. Executive Director stated there is no systematic program that collects data of the alerts trigger by room cord plugs. Executive Director stated all rooms are installed with fall detection camera which will record videos of each fall, and alert the facility via telephone. File review of standard report of March 2024 call response data provided by room camera system revealed there was a total of 14 falls detected, the median time to respond was one minute and 14 seconds with the average time to respond to be one minute and 43 seconds. File review further revealed time to respond less than five minutes was the total of 92.31%. Interview conducted with Executive Director on February 5, 2025 revealed when a call for assistance is activated from a room, it will create a ring which cannot be deactivated until staff go to the resident room to turn it off when they respond. The allegation above is unfounded.

Allegation: Staff do not meet resident toileting needs.

Based on LPA's observation to seven bedrooms on April 3, 2024 and five bedrooms on June 21, 2024, there was no indication of incontinence mal odor. Interview conducted with R1 on March 22, 2024 revealed R1 does not have any issues with staff not fulfilling resident toileting needs. Interview conducted with R2 revealed R2 is happy and does not have any current issue regarding incontinence care. Interview conducted with Health and Wellcare Director revealed that she does not have any issues with staff not assisting residents with toileting and/or incontinence care. Health and Wellcare Director stated residents in care are changed and/or assisted with toileting needs before bed. Night (NOC) shift are not to disturb residents while they are sleeping to check their depends unless residents wake up in the middle of the night, and notify staff for a change. Health and Wellcare Director stated when morning shift starts it is usually when residents are waking up for the day which will require toileting/incontinence assistance. Residents may have had a bowel movement in their sleep at night but it does not mean residents were neglected. The allegation is unfounded.