Complaint Investigation Report

Regarding the allegation that the administrator is not following required 1/1 care as agreed: It was alleged that the facility has been short staffed, especially on the weekends, and that Client #1 (C1) is not receiving one-on-one supervision as required by C1’s care plan and as a result has eloped multiple times. LPA inspected the facility twice and observed that the staffing ratios were being followed. LPA interviewed the administrator who denied the allegation, stating the facility has enough staff to meet all of the clients’ needs as outlined in their care plans at all times, including C1 who needs one-on-one supervision. The administrator confirmed C1 requires one-on-one supervision and that C1 is an elopement risk, but claimed C1 always receives one-on-one supervision and has not eloped recently. LPA interviewed four staff who corroborated the administrator’s statements. LPA conducted interviews with three clients and the information obtained did not corroborate the allegations. LPA reviewed staff schedules for April, May, and June 2022 which show at least two, but more commonly three, staff assigned to each shift which would have allowed at least one staff to provide one-on-one supervision to C1.

Regarding the allegation that the facility does not purchase enough food for the residents in care: It was alleged that the food purchased for the clients is oftentimes spoiled and has to be discarded, the staff do not purchase enough food for the clients in care, and that the facility mostly serves canned foods to the residents. LPA inspected the facility and observed no spoiled or expired foods, proper temperatures in the refrigerator and freezer, purchase/expiration dates written on food items to ensure food items are not kept beyond these dates, the kitchen, refrigerator, and freezer were clean and organized, and the perishable food appeared fresh and included fresh fruit and vegetables. LPA interviewed the administrator and four staff who denied the allegation. LPA conducted interviews with three clients and the information obtained did not corroborate the allegation. LPA reviewed client weight records for four clients and noted that their weights have been stable. LPA reviewed recent grocery invoices which show the facility purchases perishable and non-perishable food weekly. The information obtained did not corroborate the allegation.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that the administrator is not following required 1/1 care as agreed and the facility does not purchase enough food for the residents in care occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.