Complaint Investigation Report

On 01/24/25 between 10:20 am- and 12:15 pm, LPA Richard interviewed one resident #1 (R1) who denied the allegation and stated it was superficial scratches on the right leg that only needed a band-aid. On 01/24/25 between 12:00 pm and 2:30 pm, LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation. They stated that they all received training on how to use the Hoyer lift before using it. The record review of the facility Shift Report (dated 01/19/25 to 01/20/25) indicated that R1 was seen by the facility nurse for a superficial scratch on the right leg, and first aid and a patch were administered. On 01/24/25, LPA did not observe any visible laceration on R1's right leg.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #2: Staff use drugs on the facility grounds.

It is being alleged that staff used drugs on work premises. On, 01/24/25, between 10:20 am, and 12:00 pm LPA interviewed eight residents #1-8 (R1-R8) 7 out of 8 stated that they had never witnessed any of the staff using drugs on the ground of the facility. On 01/24/25, between 12:00 pm and 2:30 P.m., LPA Richard interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that the facility has rules on using drugs or disorderly conducted inside or outside the facility premises. All the staff stated that the facility has a town hall each month with staff and residents to make sure the residents and staff can report to management anything they see outside the facility premises.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #3: Staff did not follow injection procedures for the residents.

It is being alleged that medication technicians instructed other staff to falsely chart insulin injections as being given on time when they had not, and the staff would administer it later. On 01/24/25, at 12: 00 p.m. LPA Richard interviewed the staff (S6) Health Services Director who denied the allegation and stated that the facility only has two residents who are in insulin injections. Continue to LIC9099-C.