complaint·September 6, 2023

Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided. Allegation #2 “Staff did not provide activities for residents. The allegation alleged that the facility had not provided activities for the residents in care for at least three (3) months. LPA Nickolas’ interview with the Executive Director revealed that the facility has an activities director, and the activities director has an assistant. LPA Nickolas' interviews with several clients in care revealed that although numerous interviews were attempted with clients in care, only one (1) client, client #2 (C2), could discuss some of the activities provided at the facility. LPA Nickolas' interview with C2 revealed that the facility offers bingo and movie nights. LPA Nickolas' facility tour revealed that several activity calendars are posted throughout the facility. The facility's activity calendars list two (2) or three (3) activities every day for August and September 2023. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #3 “Staff did not safeguard residents’ medical equipment”. The allegation alleged that the facility staff did not safeguard the client’s medical equipment. LPA Nickolas’ interviews with several facility staff members revealed that they denied this allegation. LPA Nickolas’ interviews with several clients in care revealed that the clients expressed no concern about living at the facility or could not participate in the interview process. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #4 “Staff not providing resident with comfortable bed accommodations”. The allegation alleged that the client's air mattress setting was not correct. Department staff interview with staff # 1 (S1) revealed that the hospice agency checks the settings on the air mattresses. LPA Nickolas’ interview with the Executive Director revealed that hospice orders the air mattresses, and hospice sets the setting on the mattresses, not facility staff. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #5 “Facility not prepared for emergencies” The allegation alleged that the facility had no backup plan during a power outage. The allegation alleged that during an active shooter in the area, the facility staff failed to lock down the facility but were outside trying to see what was happening. Department staff interview with S1 revealed that they were not provided active shooter training. LPA Nickolas’ interview with the Business Office Manager revealed that the Business Office Manager denied this allegation. The Business Office Manager stated the facility has generators and discussed the facility’s active shooter training. LPA Nickolas' interview with two (2) facility staff members acknowledged receiving active shooter training and were able to discuss that training. LPA Nickolas reviewed the facility’s active shooter training and emergency disaster plan. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #6 “Staff did not check on resident in a timely manner”. The allegation alleged that on numerous occasions, client #1 (C1) activated their call button and waited over an hour, and no one came to assist them. LPA Nickolas' interview with the Business Office Manager revealed that they denied this allegation. LPA Nickolas' interviews with several clients in care revealed that some clients could articulate they do not wait long for staff to assist them. While other clients' interviewed were not able to participate in the interview process. LPA Nickolas' interviews with several caregivers revealed that they denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #7 “Staff engaging in inappropriate behaviors in the presence of residents”. The allegation alleged unidentified facility staff members were fighting in the facility’s garden. Department staff interview with S1 and staff #2 (S2) revealed that they denied this allegation. LPA Nickolas’ interview with an additional four (4) facility staff members denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and copy of this report was provided.