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32 | Regarding the allegation that the facility call light system is inoperable, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records, including paging system activity reports.
Interviews conducted with staff revealed the facility uses a functioning call light system which alerts staff when residents activate pull cords. Staff stated residents are monitored throughout the day and staff respond to resident needs. Staff stated that during WiFi interruptions, staff conduct routine rounds and safety checks on residents. LPA reviewed facility records related to the call light system and observed the system was operational. Although some records reflected longer reset times, the facility staff stated this may occur when staff do not fully reset the pull cord system after responding to residents. Interviews and records reviewed did not reveal sufficient evidence to support that the call light system was consistently nonfunctional or inoperable. 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 the allegation that staff did not provide residents with adequate meal service, Licensing Program Analyst (LPA) conducted interviews and reviewed facility records including facility menus and alternative menu options. Interviews conducted with staff revealed the facility provides residents with three daily meals as well as alternative meal options when requested. Staff stated residents are offered substitutions if they do not prefer the meal being served and residents are encouraged to eat throughout the day. LPA reviewed facility menus which documented a variety of meal options and alternative menu selections available to residents. Interviews and records reviewed did not reveal sufficient evidence to support that residents were not being provided adequate meal service. 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 the allegation that the facility did not employ adequate staff to meet the needs of residents in care, Licensing Program Analyst (LPA) conducted interviews and reviewed facility staffing schedules and records. Interviews conducted with staff revealed the facility maintains staffing coverage throughout each shift and staff stated they are generally able to respond to resident needs in a timely manner. Staff acknowledged there are occasions when resident calls increase during busy periods; however, staff stated assistance is available from other staff members when needed. LPA reviewed staffing schedules and did not observe sufficient evidence to support that the facility failed to employ adequate staff to meet resident 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.
Exit interview conducted with facility, Cognitive Care Director, Ashley Mendoza, and copy of report provided |