Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff are not knowledgeable of residents current health conditions.

It is being alleged that facility staff is unable to communicate residents health conditions to emergency personal. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7, 7 of 7 residents interviewed denied the allegation above and reported feeling safe when assisted by staff. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported staff are comfortable communicating with emergency personal.

Allegation: Staff do not ensure adequate care and supervision is being provided to resident’s care.

It is being alleged that residents in care have been left on the ground before facility staff will assist.

On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7, 3 of 7 residents interviewed denied experiencing falls while receiving care at the facility, 1 of 7 reported having a witnessed fall and received help in real time, 2 of 7 residents interviewed reported having an un-witnessed fall that did not require staff assistance, and 1 of 7 residents reported having an un-witnessed fall and received assistance within minutes after calling for help. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported that when a resident is observe to be on the ground a med tech is called to assess the resident before the resident is moved and before the staff calls 911 if needed. 5 of 5 staff also reported that caregivers will respond to call light/pull light right away or will ask med techs to assist if the caregiver is unable to respond right away. On 03/14/25 LPA conducted a tour of the facility and conducted a call button tests, LPA observed caregivers to respond to call within 5 minutes.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Executive Director and a copy of this report was provided.