complaint·July 17, 2025

LPA reviewed current in-service training conducted on 1/10/2025 residents’ rights, 2/25/2025 In-service-reporting trainings, and 4/7/2025 Medication Administration (MARS)Training's signed by staff members. Investigation revealed the following: 1 Allegation: Staff do not prevent a resident from suffering multiple falls while in care. Interviews with staff members (S1-S10) stated residents are closely monitored throughout the day & night and are not left unattended for extended periods. For residents identified as fall risks, staff maintain close supervision, either by remaining nearby while assisting other residents or by coordinating with additional staff to ensure continuous observation and support is provided to residents. LPA also interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members help them with their needs and have not fallen. The remaining 8 residents were unable to engage in a clear conversation. A random audit of resident files (R1-R6) and Special Incident Reports (SIRs) in the Community Care Licensing (CCL) database revealed no incident reports indicating that a resident death resulted from a fall. Furthermore, LPA reviewed UIRs for residents who had passed away and confirmed that their causes of death were unrelated to falls. During a facility tour, LPA observed staff actively assisting residents, with no individuals appearing to be left unattended. Based on these observations, it appears that residents receive consistent supervision, and staff have a structured plan in place to promote safety and prevent falls. LPA reviewed current in-service training conducted on 2/25/2025 and 4/7/2025, Medication Administration Training's signed by staff members. 2. Allegation: Untrained staff administer medication On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that, to their knowledge, all medication technicians (MedTechs) are certified to pass out medications. During the investigation, LPA observed that the MedTech certifications for S7 and S9 were up to date and dispense medications. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications, and LPA requested and obtained staff training records for MedTechs. LPA observed re-certifications through Elite Medical Academy for S1, S2, S3, and S8. Interviews with staff also indicated that they have not seen staff members S4, S5, and S6 dispensing medications, and there are no records of current MedTech training for these staff members, only in-service training's. 3 Allegation: Staff handle residents in a rough manner. On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - 10 (S1–S10), Of all the staff interviewed 10 out of the 10 staff stated residents have not been handled in a rough manner that could have resulted in injuries to any resident in care. LPA interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that 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. An exit interview was conducted, and a copy of the report was provided to the Joel Niblett- Administrator at the conclusion of the visit with appeal rights.