Complaint Investigation Report

until a later time to be addressed since the care staff was needed to provide direct support and supervision to the residents.

The preponderance for the standard of evidence has been met and the department finds the allegation, "Staff do not ensure resident rooms are kept clean," to be SUBSTANTIATED . This deficiency has been cited on the LIC 9099 D page.

Regarding the allegation: "Staff do not ensure that resident has a working call button."

Based on interviews with 3 staff members, residents in memory care do not have a working call button to alert staff that they need assistance. There were no call buttons located at their bedsides and S7 stated,

"That is probably why we had so many unwitnessed falls; they don't have a way to ask for help when they want to get out of bed."

On 6/14/24, this LPA observed the alert system set up in the bathrooms in memory care including room 225. The pull cords were wrapped around the units and therefore could not be activated. The units also had a button that could be pushed, but as there was no signage or markings on the plain gray circle, it was not obvious that it was a button or what would happen if it was pushed. LPA took photos for documentation purposes.

Based on interviews and observations the allegation, "Staff do not ensure that resident has a working call button," has been SUBSTANTIATED. The preponderance for the standard of evidence has been met and this deficiency has been cited on the LIC 9099 D page.

Regarding: "Staff do not follow infection control practices."

Based on a review of the housekeeping schedule and interviews with 3 staff members at a supervisory level, at the time of the complaint, staff were wearing necessary PPE when required due to the health status of residents in care. However, due to limited staffing, rooms were not being cleaned immediately following resident's toileting accidents and staff were not preventing residents from wandering the floor and touching surfaces that had not been disinfected. 2 of the 3 staff members interviewed stated that the restrooms in the common areas of memory care were not being disinfected between resident use.