complaint·December 13, 2023

Based off interviews and statements conducted with staff, six of six staff state they try to meet the needs of their residents as best as they can, respond to calls within 10 to 15 minutes and has sufficient staff on site. Interviews revealed that during 2020 to 2021, facility used staffing agencies to help fill in shifts. Interviews with Four of Four staff responsible for medications stated resident 1 received medication as prescribed however mentioned that resident 1 medication times would vary depending on resident’s schedule. Interviews with staff revealed resolution in Resident 1’s medication schedule. Interview with Resident 1 revealed that Resident 1 stated they have no issues with staffing and stated staff assist with ADL’S such as showering, toileting, medication and transporting to facility dining area. Interview revealed that resident confirms if they have an issue with facility, they bring attention to issue. Resident confirms they like living at facility and feels safe in facilities care. During investigation, LPA reviewed documentation and investigation revealed the following: Facility Assessment records dated from 3/29/2020 to 11/28/2023 revealed that Resident 1 has daily status checks 4 times per shift, 12 times a day. Facility Assessments are updated every 6 months. Hospice Records revealed that Resident 1 received weekly showering and wound care from 9/16/2020 to 12/23/2020. Facility notification revealed discontinued Hospice care for Resident 1 on 1/29/2021. This department has investigated these allegations and based on LPA’s observations, and interviews which were conducted investigation revealed conflicting reports. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur as reported, therefore the allegations are all deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator and a copy of report along with LIC 811 Confidential Names List was provided.