complaint·November 6, 2025

Staff do not ensure staff meet training requirements.-UNSUBSTANTIATED It was reported that some caregivers do not have all the training hours to be working on the floor. LPA observed a competency verification form that is filled out by the new employee in the first four days of employment as they complete each training and is verified by the Business office manager. This allegation is unsubstantiated. Staff does not ensure resident's files are properly stored. - UNSUBSTANTIATED It was reported that resident's files are not locked away in a cabinet. On 09/28/2025 LPA toured the facility and observed the door to the business office to be locked, this ensured that resident and staff files are properly secured. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.