complaint·June 21, 2022

Interviews with residents revealed 3 out of 6 residents stated not being able to recall whether or not participated in the appraisal needs and care plan process. 2 out of 6 residents stated to have not been a part of the appraisal needs and care plan. 1 out of 6 residents stated to not need care and not caring for a plan. Administrator stated that three staff meet with residents in the activity area and review the appraisal needs and care plan with residents, unless the residents are under ALW program, then social worker (SW) and nurse (LVN) meets with residents and after assistant administrator is provided a copy. 3 out of 3 staff interview stated to review the appraisal needs and care plan with the residents in the activity area as often as needed, per changes in condition or changes in care for residents needs. Documents review revealed 4 out of 5 appraisal needs and care plan were signed and dated 1/1/22 and 1 out of 5 had noted "resident refused to sign" and dated 1/1/22. ISP reviewed for R1 was signed and dated on 3/4/22. Phys cian's report reviewed noted 5 out of 6 residents need some assistance with a few daily living activities and 1 resident does not require any assistance. 6 out of 6 residents are self responsible allowing them to make decisions for themselves. Staff payroll list for 1/1/22 lists the staff responsible for appraisal needs and care plan worked on the day the appraisal needs and care plan were signed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview was conducted with Peter Babaian Administrator and a copy of this report was provided.