Complaint·December 18, 2023

Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA interviewed Staff and Administrator. LPA obtained copies of staff schedule, records and R1's file. R1 has an incontinence schedule showing when checked/changed. Records show R1 is being checked/changed every 2 hours. LPA reviewed activties schedule and obtained a copy of the schedule. Last week the facility had a Christmas party, music, movies, and religious services ect. Based on record review and interviews, it is undetermined whether or not the allegations occurred. 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. An exit interview was conducted with the Administrator and a copy of this report was provided.