complaint·January 27, 2025

Facility documentation indicated resident signed on own for flu vaccine and indicated receiving the Pfizer covid vaccine. There is no documentation of a durable power of attorney (DPOA) at the facility for R1 and document checklist does not show that a DPOA was received by the facility. Interview with Administrator at time of complaint denied knowledge of any falls. Facility does not have documentation of any falls and care plan states no history of falls. Facility does not have any documentation of hospitalization for a fall for the resident. Facility staffing levels are as follows: Three caregivers in Assisted Living and Memory Care and 2 med techs for 1st and 2nd shift and 1 caregiver and med tech for NOC shift. Three out of three staff and five out of five residents state current staffing levels are good and resident needs are being met. Interview with former Administrator indicated struggling with staffing during the pandemic and using agency to fill holes. Facility Administrator denies facility advertises having an RN on-site and state the facility employs an LVN only. Current facility website does not advertise any nursing staff. Due to the age of the complaint, facility is unable to provide all documents and/ or records requested by the department. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did occur. An exit interview was conducted and a copy of this report was provided to a facility representative.