complaint·July 20, 2021

Based on interviews conducted, record reviews, and observation it was revealed that licensee was able to meet the care and supervision needs of residents utilizing the staffing resources available on 6-30-21, 7-1-21 and 7-10-21. As a result, the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED. Allegation #3: Residents not provided quantity or quality nutritious meals: LPA conducted interviews with residents on 7-7-21 and conducted observation of lunch meal on 7-7-21. LPA also reviewed facility’s current menu. Based on interviews with residents and staff it was revealed that residents were satisfied with the quantity and quality of food served. Based on LPA’s observation and review of menu, it was revealed that food portions were of adequate size and quality presentation. Review of menu also revealed that scheduled snacks and desserts were available. Based on observations, interviews, and record reviews it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED. Allegation #4: Resident incidents not reported: LPA conducted staff interviews and record reviews on 7-7-21. Record reviews and interviews revealed an incident occurring on 6-30-21 which was reported to the Department within appropriate time frame. Additional record reviews of past incidents revealed reporting requirements were met. Incident from 6-30-21 was reported during LPA’s visit on 7-7-21. Based on record reviews and interviews, it is determined that the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED. Allegation #5; Residents not provided safe accommodations: LPA conducted staff interviews and facility observation on 7-7-21. LPA toured facility inside and out including memory care unit. LPA did not observe any dangerous objects accessible to residents or other unsafe accommodations. Based on interviews, it was revealed that contractors are not scheduled to conduct work in the memory care unit. Staff interviews also revealed no witness of contractor work in memory care unit on the night of 6-30-21 or during the early morning hours of 7-1-21. Doors in memory care were functioning appropriately and provided adequate security based on LPA observations on 7-7-21 and 7-10-21. Based on observation and interviews, it is determined that the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged incident occurred.