complaint·January 26, 2024

Records reviewed and collected on 11/02/2023 show that 1 of 4 residents have a diagnosis of dementia, and 4 of 4 residents require assistance in bathing, 1 of 4 are not able to bath themselves, as indicated residents Physician Orders (LIC602). On 11/02/2023 LPA Jeffries requested in report LIC9099, the following: “All staff of Facility, actual hours worked September - October 2023, -Job descriptions and job duties, -All staff training past 12 months. …” Facility Administrator only provided training for one staff (S1). The training records provide for S1 indicated the following training: Drivers Training 08/09/23, 1.5 hours, Med assist training 08/04/23, 4.5 hours, Orientation 07/28/23 5 hours, CPI (Crisis Prevention Institute) Online 09/23/23, 2.5 hours, CPI In-person, 09/23/23 6.25 hours. LPA noted that there was no indication of basic first aid, CPR (Cardio-Pulmonary Resuscitations), or dementia training for S1. On 01/25/2024 at 4:46PM, Executive Director, Sean Denich emailed LPA Jeffries with additional documentation which did not show any additional training for S1. Additionally, facility time records for the same months showed no different compelling findings than the original time sheet documents submitted at the beginning of this investigation. LPA conducted an interview with S1 on 11/02/2023, where S1 stated that they have been left alone with residents without any training for several days and some residents left for day programs without having time to eat breakfast. Based on documentation, and interviews, the allegations of, “Due to insufficient staffing resident’s needs are not met.” and “Staff do not have proper training. “ and both are substantiated at this time. As to the allegation of, “Facility has mold.” It was alleged that the facility had dangerous mold in the on-suite bathroom. On 11/02/2023 LPA Jeffries observed and photographed black mold on the bathroom vanity in facilities on-suite bathroom. LPA noted that before LPA to make the observation, facility maintenance personal S4, was observed walking out of the facility with two hands full of molded wallpaper, which matched the remnants of the wallpaper that was in the bathroom vanity. LPA noted that mold mediation was started on this date (11/02/2023). LPA interviewed S1 on 11/02/2023. S1 stated that they had reported the mold to the facility Administrator during the first week of September 2023. Based on observations, photographs, interviews, and mold mitigation efforts during the visit, there is enough evidence to support the allegation of, “Facility has mold.” and the allegation is substantiated at this time. Exit interview, report read, citations issued, appeal rights and report provided. Based on documentation, and interviews, there is not enough evidence to support the allegations of, “Staff did not provide medical attention to residents in a timely manner.” and “Staff did not assist residents with obtaining medical appointments.” and are both unsubstantiated at this time. Exit interview, report read, and report provided.