Complaint Investigation Report

(Continued from LIC9099) On 11/26/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch . On 1/16/2025, LPA returned to the facility to continue the investigation. LPA obtained photos of the following documents: criminal record clearances, physician's reports and health screenings.

Regarding the allegation of "Staff do not have fingerprint clearance," LPA reviewed staff files and observed Criminal Record Clearances in all staff files. LPA also reviewed the facility's personnel records through Guardian and observed 6 out of 6 staff have been cleared to work at the facility.

Regarding the allegation of "Staff insert suppositories to residents in care," LPA interviewed the 5 residents in care and all of them stated the facility does not insert suppositories or other medication into them rectally.

Regarding the allegation of "Staff did not maintain resident records," the allegation indication LIC602s are missing or outdated in resident files. LPA observed LIC602s all resident files. 4 out of 5 LIC602s were created in 2024. 1 out of 5 LIC602s was created in December 2023.

Regarding the allegation of "Residents are not provided proper food service," LPA interviewed 5 residents in care. Of the residents interviewed all stated they are provided proper food service and have no complaints.

Regarding the allegation of "Staff did not inform resident's physician of resident's change of condition," LPA reviewed resident files and noted one resident with dementia. LPA observed an admission agreement for this resident stating they moved into facility on 7/24/2024. LPA observed a completed physician's report indicating the resident has dementia. This report was signed by the resident's physician and dated 8/23/2024.

Regarding the allegation of "Staff did not ensure sufficient food items were available at the facility for residents in care," LPA observed the food supply in the facility. LPA noted the facility has 7 day supply of non-perishable foods and a 2-day supply of perishable foods. LPA conducted interviews with 5 residents in care. Of the residents interviewed, all stated there is enough food in the facility and that they receive enough.

Regarding the allegation of "Centrally stored medications are accessible to residents in care," LPA observed medications to be locked in a kitchen cabinet behind a lock that requires a key to open. Of the residents and staff interviewed, all stated medication remains locked in the kitchen. (Continued on 2nd LIC9099-C)