complaint·October 23, 2025

The investigation into the allegation, facility does not have complete resident records, revealed the following. It was reported that Resident 2 (R2) did not have a care plan and no medication records. A review of facility records shows R2 moved in September 24, 2021 and had a care plan dated September 23, 2021 and a care plan dated October 6 and a medication list for September 2021. LPA reviewed 3 other resident files for Resident 1 (R1), Resident 3 (R3) and Resident 4 (R4). No discrepancies observed. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility did not have a resident appraised, revealed the following. It was reported that R2 was not appraised. R2 moved into the facility September 24, 2021. A review of R2's records shows R2 was assessed on September 23, 2021 prior to move in and assessed on October 6, 2021 after they moved in the facilty. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility staff is not properly trained, revealed the following. It was reported that Staff 1 (S1) had no training, experience or certifications. A review of records shows S1 had over 24 hours of training and 16 hours of on the job training (one on one training with another caregiver) in topics such as, care of residents with Dementia, basic care skills, providing medication assistance, resident rights and CPR certification. A review of 3 other caregiver files showed all 3 caregivers had 40 hours of initial training. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staffing is not sufficient to meet resident's needs, revealed the following. It was reported that a lack of staff has resulted in multiple falls from residents. It also was reported that Resident 5 (R5) passed away at the facility. A review of records shows, R5 was sent to the hospital on July 9, 2021 and never returned to the facility. R5 passed away at the hospital on July 15, 2021. A review of the staff schedule for October and September 2021 show 18 caregivers and med-techs. 2 caregivers and 1 med-tech are scheduled for the AM shift (6am - 2pm) and PM shift (2pm-10pm). 1 caregiver and 1 med-tech for NOC shift (10pm - 6am). The Executive Director reported they are in the process of hiring more staff but at this time they only have 14 residents so there is enough staff to care for all the residents. 5 out of 5 staff reported there is enough staff to meet the needs of the residents. A review of incident reports received for September and October 2021 show only 2 incidents reports were received from the facility. One report noted a resident was found sitting on the floor and the other report noted a resident was lethargic. Neither report raised any concerns for the Agency and did not require follow up. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.