complaint·October 19, 2023

On 10/19/2023 Licensing Program Analyst (LPA) M. Garza completed an unannounced complaint visit to deliver findings. LPA met with Administrator, Jenny Penner, explained reason for visit. During the investigation, LPA reviewed documentation (schedules, staff roster and contact information, training records) and completed interviews with staff. Interview with Administrator indicated that there have been new staff that was hired. Upon review of the training records, it was observed that 4 of 4 staff did not have the required number of hours of training and 3 of 4 did not have the required training covering hospice, dementia, resident rights and change in condition). It was also indicated that the facility was not following COVID guidance by the most strenuous restrictions set forth and were using staff to cross cover for positive and negative residents. The allegations listed above have met the preponderance of evidence standard per Title 22. The allegations are SUBSTANTIATED. Deficiencies cited on 9099D. Exit interview completed. A copy of this report and appeal rights given.