complaint·January 13, 2023

An additional four (4) hours of initial medication training must also be completed within the first two (2) weeks of medication staff employment”. Page nine (9) of the facility’s program description on medication training further states, “after completing ten (10) hours of training, the employees will be tested on their comprehension and competency in medication assistance. The test result will be filed in the employee’s personnel file. In each succeeding twelve (12) month period, an additional eight (8) hours of training will be conducted with the employee on medication-related issues”. The Licensee failed to provide sufficient evidence that staff dispensing medication were qualified as outlined in the facility’s program description. Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation 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 provide. Allegation #2 “Staff are not adequately trained”. The allegation alleges that on April 5, 2022 or April 6, 2022, the RP does not believe that the facility staff received proper training based on the reprimand they overheard from a staff member that quit. LPA interview with Licensee revealed that staff was provided compact disc (CD) training from a company called Care and Compliance group. The Licensee also provided documentation of facility staff training. LPA interview with facility staff #2 (S2) revealed that Digital Versatile Disk (DVD) training videos were provided. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Allegation # 3 “Staff did not notice a change in resident's condition”. The allegation alleges that on April 5, 2022 or April 6, 2022, C1 was observed by the RP lying on the floor. RP states that C1 was lying on the floor in their room and bleeding badly at the top of their head. The RP further stated that C1 lay on the floor for some time, and staff did not check on them or notice any changes in their condition. LPA interview with the Licensee revealed that C1 did not suffer any injury on any of the alleged dates. LPA interview with staff #1 (S1) revealed that C1 did fall, but S1 did not remember the exact date. However, S1 did provide a time frame, using weeks, and that time frame excluded April 5, 2022, or April 6, 2022. S1 also stated that 911 and the house manager were called when C1 fell. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Allegation #4 “Staff yelling at resident”. The allegation alleges that on April 5, 2022 or April 6, 2022, The RP overheard staff yelling at a resident. LPA interview with the Licensee revealed that no client or another member of the Licensee’s staff has ever reported to the Licensee that staff is yelling at a resident. LPA interview with S2 revealed that they had not received complaints from staff or clients about staff yelling at a resident. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Based on the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.