complaint·January 29, 2025

Allegation: "Licensee does not ensure facility is adequately staffed to meet residents' needs:" LPA interviewed staff, residents, and family members and reviewed staff schedules related to this allegation. LPA noted that 1 (one) staff is scheduled for this facility at all times. Interview with staff revealed that during times when residents require showering, an additional staff comes from another of the licensee's facilities nearby and will assist the staff at this location. It was also noted that the licensee's office is located on this facility property, so during normal business hours Monday through Friday, the facility designee is present at this facility. Staff interviewed stated that either the facility designee or staff from the other facility cover breaks and assist in the facility as needed. Interview also revealed that when a new resident moves in, there are 2 (two) staff scheduled. Additionally, if a new resident moves in that has higher needs or behavioral expressions, the staff schedule is adjusted to meet resident needs. Interview revealed that the residents that reside at the facility at this time do not have unsafe wandering behaviors. Residents interviewed stated there is enough staff at the facility to meet their needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: " Staff are not properly supervising residents who may be a fall risk:" The complaint alleges that during an undisclosed time, while staff was assisting a resident, another resident fell. LPA inquired with staff, residents, and facility designee related to falls. All persons interviewed stated there have been no falls at this location in some time. During both the initial visit and the subsequent visit, LPA observed residents in the facility to be seated in common areas or in their own rooms. LPA also observed residents self-ambulating during both visits. Staff indicated that 3 (three) of the 4 (four) residents are able to ambulate safely independently. 1 (one) resident does require an escort while ambulating, but staff are able to assist this resident. Additionally, the resident does have a motion alarm which alerts staff when the resident stands up to ensure this resident is assisted as needed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099-C Allegation: "Staff did not prevent resident from wandering from facility:" The complaint alleges that a resident wandered out the front door while the staff was busy assisting another resident. LPA interviewed staff and facility designee, all of whom stated there are no current residents who engage in unsafe wandering. Staff stated there was a resident a long time ago that did attempt to elope from the facility, but that the facility designee did accompany the resident out the front door into the facility driveway before redirecting the resident inside. The resident was supervised at all times. LPA noted that the facility does have an auditory alarm on all exit doors, which were observed to be functional during both visits. Staff interviewed indicated that at times when they have had a resident that engages in unsafe wandering, there have been 2 (two) staff scheduled to ensure adequate supervision for the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted with facility designee. A copy of today's report was provided.