complaint·July 20, 2023

Staff remove interior door knob(s) to prevent resident(s) from exiting. On 1/26/2022, LPA observed front door's door knob was intact with turn lock. Interview with residents indicated the front door was operational without missing door knob. Centrally stored medicines are not kept in a safe and locked place. On 1/26/2022, LPA observed medications were locked in the medication cabinet. LPA did not observe unlocked medications on visits dated 1/26/2022 and 7/14/2023. Night supervision staff are not available to assist in the event of an emergency. Interview with staff revealed that call button system is wireless and on call night staff will take the wireless system with them to the caregiver's room at night time. There are two live-in staff at the facility. Interview with residents indicated that night staff would assist residents when call button is activated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.