complaint·January 23, 2024

Licensing Program Analyst (LPA) Tiffany Holmesconducted an unannounced visit to deliver findings for the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Jenna Purnell, Wellness Director. On December. 22, 2023, Community Care Licensing (CCL) received a complaint alleging staff did did not follow resident's care plan. During the investigation, LPA Holmes collected pertinent resident records as well as facility documentation and conducted interviews. Interviews revealed that the resident has been livng at the facility since 08/01/2015. The care plans that were observed were completed on 12/12/2021 and again it was updated on 11/07/2023. Based on the two care plans observed, Resident 1(R1) did not have anything written or documented stating that they have a Do Not Resuscitate (DNR). Interviews with staff revealed R1 has no had a DNR on any of their care plans. Interviews with staff revealed they do not recall any documentation being provided to them from the family or from St. Pauls Pace. There is no information to corroborate the allegation. Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Jenna Purnell, Wellness Director , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.