The Program Coordinator conducted a camera review of overnight staff on the green and orange unit during the following times:
- Green 1:00 AM – 1:43 AM – Staff can be seen conducting bed checks within ten minutes or less on multiple occasions.
- Orange 3:17 AM – 5:30 AM – Staff completed checks at 3:17 AM, 3:32 AM, 3:59 AM, 4:38 AM, and 5:30 AM.
The lapse of thirty minutes or more between nightly visual check of the residents is a violation of the minimum licensing standards. While walking through a unit, a resident reported that the facility is also not addressing the resident’s concerns. When asked what the residents do to report their grievances, the resident reported that they put them in the grievance box, but the box is full, and nobody is reading them. The Program Coordinator had the CEO show the Coordinator the grievance box which was visibly full. The CEO did not have a key to the box, staff did not have a key to the box, and maintenance was unsure if any of the multiple keys he has would open the box. The Program Coordinator discussed the importance of hearing the residents’ grievances and encouraged the facility to block off the box if they do not intent to use it. The CEO reports that she will inform the staff and residents of a different process in which staff take the grievances directly to the therapists or CEO’s mailbox for review.
Regulations not correctable: 907.6 – night shift staff on the orange unit 5/22/23 were not conducting visual checks on the residents a minimum of every thirty minutes. Licensing Specialist: Chelsea Vardell.