Complaint·February 9, 2024

The investigation revealed the following: Regarding the allegation "Facility doors in disrepair," interviews conducted indicated the following: three out of eight residents interviewed agreed with the allegations and five out of eight residents were unaware of a damaged door. During the facility tour, LPA noticed three doors that were in disrepair and one open garage gate. The first door is down the stairs near the second-floor lobby. The second door is down the stairs near the skilled nursing area. The third door is outside near the smoking patio. LPA also observed two residents reaching through the outside fence screening to open the door from the inside. Regarding the allegation “Facility doors in disrepair," based on interviews and observation, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Administrator Aaron Mayes. The investigation revealed the following: Regarding the allegation “Staff are not safeguarding residents' belongings," interviews conducted indicated the following: seven out of eight residents interviewed had not heard about residents’ belongings being stolen. Eight out of eight staff members have not heard about residents’ belongings being stolen. Record reviews indicate that eight out of eight residents have theft and loss policy on file. Based on the interviews and record reviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and technical assistance provided. A copy of this report was reviewed and left with Administrator Aaron Mayes