Complaint·December 9, 2021

A plant inspection of the facility was conducted on 12/20/2020 virtually and in person on 12/09/2021. Investigation revealed: Allegation: Staff allowed residents to wander away from the facility. It is alleged the staff allowed residents to wander away from the facility. Residents (R1-R3) did not have any concerns regarding the care and supervision being provided to them by the staff. Resident (R1) is non-ambulatory and stated she requires staff to help push on her chair to go outside. Resident (R2-R3) stated they do leave the facility but at their own will and let the staff know anytime they leave the facility. Staff (S1-S3) stated they have never had a missing/AWOL resident. LPA spoke to witness (W1) and he stated he has never seen or had an issue with resident (R6) wandering away from the facility. LPA spoke to witness (W2) and she stated there has been no issue of “getting lost” and staff follows resident (R5) if he goes outside. LPA did not see any incidents reported regarding a resident ever missing/AWOL. Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility not administering medications as prescribed. It is alleged the facility is not administering medications as prescribed. Residents (R1-R2) stated they have not had an issue with medications being administered. Residents (R1-R2) stated they have never missed taking their medications. Staff (S1) stated there has been medication training for each staff. Staff (S1) stated staff (S1) monitors/audits the medications administered for all staff for the facility daily. Staff (S1) stated staff (S1) ensures medications are being given as prescribed and the Medication Administration Records (MAR) are being kept up to date. LPA spoke to witness (W1) and he stated there has never been an issue with medications and the facility has the meds under lock and key. LPA spoke to witness (W2) and she stated no issues with medications as prescribed. LPA received medication training logs for staff. LPA reviewed current MAR and found no issues. Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated An exit interview was conducted with House Manager Naome Leibov and a hard copy was provided.