complaint·May 25, 2023

Continued from LIC 9099... With respect to the allegation of staff did not seek timely medical attention for resident , staff were interviewed, clients were interviewed. In addition, Incident Reports were reviewed, and medical records were reviewed. It was determined that R1 had an unwitnessed fall 2/26/2026 but was being treated appropriately according to his care plan. Upon discovering R1's injuries, staff called paramedics and sent R1 to the hospital on 2/26/2023, minutes after discovering his injuries. Incident reports and medical records support the chronology of events therefore the allegation of staff did not seek timely medical attention for resident is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report and appeal rights were provided. Continued from LIC 9099A... The other clients who alleged the assault, got their information about the assault from R6. Their accounts were inconsistent, and none of the clients witnessed the incident themselves. The victim, R1, suffers from Dementia and does not recall the assault or the fall. Medical records were reviewed. R1 was seen on 2/26/2023 for the unwitnessed fall, and on 3/2/2023 after reports of being assaulted were made. According to the medical records there were no new injuries on 3/2/23 and no evidence to support he had been assaulted. As a result of the interviews conducted and the records reviewed the allegation of due to lack of staff supervision, resident had a physical altercation with another resident resulting in injury is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen interviewed staff members, interviewed clients, reviewed law enforcement incident reports and facility records. It was determined that on multiple occasions residents have left the facility unassisted however there was no evidence found to support that residents left without staff knowledge. The facility maintains a sign out log for residents which does contain entries of residents leaving over the course of the last 3 months. The facility also maintains a log of notes regarding any unusual incidents and there were no entries observed for the year of 2023 that would indicate an elopement without staff knowledge. Based on the interviews conducted and the records reviewed the allegation of resident eloped without staff knowledge is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen observed food preparation on 5/25/23, 4/28/23 and 3/20/23. LPA Jensen confirmed with site supervisor Stephanie Siewe that all staff completed ServSafe training in April and May. At this time all kitchen appliances are in good working order. There was no evidence of pest infestation observed. LPA Jensen asked kitchen staff to show LPA the cleaning supplies used for the kitchen and demonstrate cleaning protocol which was determined to be adequate. Based on observations made over the course of multiple visits the allegation of food is not prepared in a sanitary manor is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were given.