Complaint Investigation Report

Regarding: Staff do not have required training.

I t is alleged that staff have not completed required training.

Review of staff files by LPA during today’s visit revealed that S3 and S4 do not have a current First Aid/CPR certification. Interview with S1 indicated that S3 and S4 have not taken the recertification training for First Aid/CPR because S1 did not monitor the expiration dates and did not follow up on reminding staff to recertify. Based on record review and staff interview, the allegation that staff do not have the required training is corroborated.

Regarding: Facility does not have a disaster plan.

It is alleged that the facility does not have a disaster plan.

Review of records conducted by LPA during today’s visit revealed that the facility does not have a copy of the Emergency and Disaster Plan in the facility. Interview with S2 indicated that they do not know where the plan is kept in the facility and therefore, was unable to provide LPA with a copy during visit. Interview with S1 revealed that the facility does not have a hard copy of the plan in the facility. S1 stated that they keep a copy of the plan on their computer, however; when reviewed on the computer by LPA, the Emergency and Preparedness Plan was observed incomplete. The plan was observed to be missing information in elements I through J. Based staff interviews, observation and record review, the allegation that the facility does not have a disaster plan in place is corroborated.

Regarding: Staff do not ensure fire drills are conducted as required.

It is alleged that no fire drills were conducted in the last six months.

Interview with S2 indicated that the facility conducts fire/disaster drills every month; however, record review by LPA during today’s visit revealed that the facility’s last three drills were conducted on 5/18/2024, 5/3/2025 and 1/20/2026 which were not conducted within the compliance time frame of every six months. Further interview with S2 indicated that they do not have any other records to indicate that the facility is conducting drills. Based on staff interviews and record review, the allegation that the facility is not conducting fire drills every six months is corroborated.