complaint·July 29, 2022

Investigations revealed: Allegation: Facility staff are not adequately supervising residents in care. It is alleged that Facility staff are not adequately supervising residents in care. The Reporting Party (RP) alleged a male individual screams loudly asking for help during mornings and evenings. RP added during the pre-investigation interview that another individual also screams and yells out for help. The department reviewed Residents' (R#1 and R#2) service records. Appraisal/Needs and Services Plan show R#1 speaks loudly, and he has behavior episodes of screaming, physically aggressive during Activities of Daily Living (ADL) care and verbally aggressive. A care staff closely monitors his behaviors and constantly supervises his needs. A care staff provides therapeutic communication and redirection as necessary. In addition, a 24-hour facility nurse is available. A death report shows R#2 passed away on 7/25/2022. Prior to passing, R#2 was taking medications for agitation and pain management as shown on the Physician Orders. LPA observed several medication adjustments on file. The department interviewed the licensee/administrator (S#1), two (2) facility nurses (S#2 and S#3), Activity Director (S#4) and two (2) care staff (S#5 and S#6). Based on the interviews conducted, S#1-S#6 revealed R#1 has behavior episodes of screaming and yelling and R#2 grimaces, yells and cries during ADL care. S#1-S#6 stated R#1 and R#2 cannot communicate properly due to their medical conditions; staff closely monitor their behaviors, and redirect them as necessary; their families are aware of their conditions; their primary physicians are constantly informed of their behaviors; different medications and medication adjustments were prescribed by their physicians. S#1 revealed she received a complaint from a neighbor and she has been responsive to the neighbor's concern. S#1 stated the facility provides a staffing ratio of 1 (one) care staff for two residents and LPA observed during the visits that this staffing ratio is followed and maintained. In addition to the care staff, there is at least one nurse on site and an Activity Director who also provide direct care to residents. Based on observations, record reviews and interviews, there is no sufficient evidence to corroborate the allegation above. Based on information gathered, LPA did not find sufficient evidence to support allegation "Facility staff are not adequately supervising residents in care. " Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Director of Care Mary Lou Giebel, and a copy of the LIC 9099 report was provided.