On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Staff interferes with resident phone calls. S1 stated that whenever any of the residents receive personal phone calls, they are given their privacy. And at no time does anyone interfere or eaves drop on any residents’ telephone calls.

On 05/10/23, LPA interviewed S2 about the allegation that the Staff interferes with resident phone calls. S2 stated that when residents get phone calls, S2 asks who it is, verifies who they would like to speak to, and then gives the telephone to the resident. S2 says, “ I don’t listen to their phone calls, I give them their privacy”.

On 05/10/23, LPA interviewed R1-R6 about the allegation that Staff interferes with resident phone calls. Residents R1-R2 denied the allegation and confirmed that when they get phone calls, they are given their privacy to speak alone. R3-R6 was not able to be interviewed due to cognitive impairment issues.

Based on interviews there is insufficient evidence to support the allegation: Staff interferes with resident phone calls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Regarding allegation #2: Facility does not meet resident's nutritional needs.

On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Facility does not meet resident's nutritional needs. S1 stated that the facility has a varied menu plan. It consists of protein, vegetables, fruits, and grains. S1 also stated that all the meals are nutritious. LPA observed the menu posted in the kitchen and it seems to be a varied and nutritional offering.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility does not meet resident's nutritional needs. S2 denied the allegation and asserted that the facility does offer a wide variety of nutritional meals as shown in the menu plan. LPA observed the refrigerator and its contents and there were lots of leafy greens, vegetables, milk, eggs, and meats. LPA also observed the pantry area, and it provided a mix of pantry staples.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Facility does not meet resident's nutritional needs. Residents R1-R2 denied the allegation and confirmed that they are served nutritional meals and are satisfied with the food. R3-R6 was not able to be interviewed due to cognitive impairment issues. However, LPA observed that they seemed healthy, and were having breakfast when the LPA arrived.

Based on interviews, observations, and record reviewed there is insufficient evidence to support the allegation: Facility does not meet resident's nutritional needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report continued on LIC9099-C

On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Resident's bedroom exit door is obstructed. S1 stated that there are no obstructions that block the residents’ door nor their exit. LPA did a walk-through of the facility and did not observe any obstructions blocking the exits of any of the residents’ doors.

On 05/10/23, LPA interviewed S2 about the allegation that the Resident's bedroom exit door is obstructed. S2 denied the allegation. LPA did a walk-through of the facility and did not observe any obstructions blocking the exits of any of the residents’ doors.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Resident's bedroom exit door is obstructed. Residents R1-R2 denied the allegation that there were any obstructions blocking their bedroom door. R3-R6 was not able to be interviewed due to cognitive impairment issues. LPA did a walk-through of the facility and did not observe any obstructions blocking the exits of any of the residents’ doors.

Based on interviews and observations there is insufficient evidence to support the allegation: Resident's bedroom exit door is obstructed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Regarding allegation #4: Facility does not assist resident with incontinence care.

On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Facility does not assist resident with incontinence care. S1 stated we check on the residents throughout the day. Those that need to be turned, we turn them side to side every two hours. Those that need their diapers changed, we do it 3 or 4 times throughout the day, or as needed if they are wet. Some residents need to be check on more often throughout the day. But we do assist the residents with incontinence care. Additionally, there is a hospice nurse that comes in as well to make sure their needs are being met.

On 05/10/23, LPA interviewed S2 about the allegation that the Facility does not assist resident with incontinence care. S2 denied the allegation and stated the residents are assisted with their incontinent care. S2 stated that S2 checks on the residents’ many times throughout the day to make sure they are not wet.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Facility does not assist resident with incontinence care. Residents R1-R2 denied the allegation and confirmed that they are assisted with incontinence care by the staff. R3-R6 was not able to be interviewed due to cognitive impairment issues. LPA did a walk-through of the residents’ bedrooms and did not detect any unpleasant smells due to the lack of incontinence assistance.

Based on interviews and observations there is insufficient evidence to support the allegation: Facility does not assist resident with incontinence care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report continued on LIC9099-C

On 05/10/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that the Licensee inappropriately increased resident's facility rate fees. S1 stated that S1 never inappropriately increased the residents rate fees. S1 stated that the facility sent out a 60-day notice to the residents’ representative advising them that a rate increase would occur. The residents’ representative complained of the increase and said they were not going to pay it. S1 stated that S1 is willing to work with the representative if there is an issue of a hardship but the representative is unwilling to speak to me. And as of today, I have not actually increased the resident’s rate.

On 05/10/23, LPA interviewed S2 about the allegation that the Licensee inappropriately increased resident's facility rate fees. S2 denied knowing anything about that issue. S2 is only a caregiver and doesn’t have access to that information.

On 05/10/23, LPA interviewed R1-R6 about the allegation that the Licensee inappropriately increased resident's facility rate fees. Residents R1-R2 denied the allegation and confirmed that their rate fee was not inappropriately increased. Moreover, R1 stated that R1s rent hasn’t been increased. R3-R6 was not able to be interviewed due to cognitive impairment issues.

Based on interviews, observations, and record review there is insufficient evidence to support the allegation: Licensee inappropriately increased resident's facility rate fees. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview has been conducted and a copy of the Complaint Report provided to Licensee, Rukayat Adamson.