Complaint Investigation Report

LPA did not observe a time where staff could be made available to conduct an individualized activity with a resident. The only activity that was observed was staff turning on the television for residents to watch a show or movie or playing music on the television.

According to an interview with S1, S1 stated the residents do not like the activity schedule and it has to be personal to each person. S1 stated they do activities. According to an interview with Administrator Beatrice, the facility does activities such as bingo days, music, or take them out to an outing. Administrator Beatrice stated that a staff member that used to work at the facility was the main person to do activities but that staff left earlier in the year.

On 06/13/2024, LPA Valerio observed the facility. The facility has a fire door located in between the living room and the back of the house where the resident rooms are located. The fire door is raised a few inches from the floor. On one side of the door way, there is a door threshold that acts as a ramp so residents can move from the resident rooms to the living area. However, if a resident where to go from the living room to the resident room area, a door threshold ramp is not present. During this visit, LPA Valerio observed a resident in a wheelchair attempting to go back to the bedroom. The resident was unsuccessful because the resident was unable to move the wheelchair across the door way.

According to Administrator Beatrice, the fire marshal required the fire door to be installed as such in order to be granted a fire clearance.

According to review of Regional office visit on 06/13/2023, the facility was required to install two thresholds on the fire door. Prior to receiving licensure, the deficiency was correct. However, based on LPA Valerio's observation there is only one door threshold instead of two.