Complaint·May 25, 2023

On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not providing a safe environment for residents in care . S1-S3 and W1 stated that none of the residents has ever come to them stating they did not feel safe in the facility. LPA interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Based on interviews there is insufficient evidence to support the allegation: Facility staff are not providing a safe environment for residents in care. 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. Allegation # 2: Facility staff are insufficient to meet the needs of the residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are insufficient to meet the needs of the residents. S1-S3 and W1 all report that there are sufficient staff to meet the needs of the facility. LPA Agard interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Most of the residents don’t see a problem with staffing. Based on interviews there is insufficient evidence to support the allegation: that Facility staff are insufficient to meet the needs of the residents. 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 allegations are Unsubstantiated . Report continued on LIC9099-C Allegation #3: Facility staff are not communicating properly with residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not communicating properly with residents. Staff state that they have an open-door policy where residents can come to the door and express any issues they may have. In addition, they can file a grievance with the social worker, who then logs in the grievance, and tracks the outcome. W1, also states that there is an open-door policy for the residents as well as the grievance process. LPA interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Most of the residents don’t have an issue with the staff and communication. Based on interviews there is insufficient evidence to support the allegation: that Facility staff are not communicating properly with residents. 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 allegations are Unsubstantiated. Report continued on LIC9099-C Allegation # 4: Facility staff are not properly trained to assist residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not properly trained to assist residents. S1-S3 and W1 state that they receive ongoing in-service training monthly as well as training through Relias. During a record review, LPA reviewed the staff scheduled for October and November of 2022. LPA did not identify any patterns of the facility having insufficient staffing. LPA did not identify any safety concerns, lack of communication with residents or staff not being properly trained based on residents’ interviews. Report continued on LIC9099-C Based on interviews there is insufficient evidence to support the allegation: that Facility staff are not properly trained to assist residents. 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 allegations are Unsubstantiated. No deficiencies were cited during this visit. An exit interview was conducted with Teresa Starks, Deputy Administrator, and a copy of the complaint report was provided.