complaint·August 15, 2023

R1's Records: Physicians Report, Pre Appraisal, Appraisal Needs and Service Plan, House Call Medical Records, Hospital Records, Admission Agreement. LPA also interviewed 5 Additional Residents and 6 Staff. The investigation revealed the following: Allegation: Facility staff did not reappraise resident. It is alleged that the facility did not appraise and/or reappraise R1 to determine their individual needs and services. Based on R1's record review it was observed that there was a Pre-Appraisal conducted for R1 on 7/26/19 and Re-Appraisals conducted on the following dates: 8/23/19, 8/25/20, and 7/1/21. R1 passed on 7/24/21 while on hospice care at Redell Pine Board and Care . Based on interviews with Staff 1 (S1) and Staff 2 (S2) the residents are reappraised yearly and as needed to ensure the facility is able to meet the needs of the resident. Allegation: Facility staffing was insufficient to meet resident's needs. It is alleged that no one at the facility was adequately monitoring and supervising R1. During record review of R1 it was observed that R1 did not have a one on one caregiver. Interview with S2 indicated that R1 was on 2 hour room checks or as needed. During investigation LPA reviewed staff roster, current staff schedule and staff schedule from June-August 2021. The review of scheduling and staff interviews (5 out of 6 staff interviews) indicated sufficient staffing is available. S1 and S2 indicated that the use of an agency is utilized in the case of a staff shortage or call outs. LPA interviewed R9-R13 today and LPA Kruz interviewed R1-R8 during initial visit and 12 out of 13 residents denied the above allegation. Although, some may have stated the facility could use some more staff (as personal preference) residents agreed that they are being cared for well and in a timely manner to meet their needs. Based on observation, record review and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided to Administrator Pam Ogot.