Complaint Investigation Report

Outside sources interviewed expressed no concerns with the way the facility administered medications and did not advise any known errors. The resident in question was unable to be interviewed.

Regarding the allegation, "Licensee did not meet resident's needs", it was alleged that staff did not check on Resident 1 (R1) during a specific timeframe. Staff interviews consistently revealed that R1 was checked on every 1-2 hours for incontinence care and due to being a fall risk, and that the door to R1's bedroom typically remained open. Staff interview further revealed that staff checked on R1 via a combination of walking into the room to speak with them, or observing them from the hallway. During the timeframe in question, staff interview revealed that R1 was observed to be sleeping and unable to be checked. Records review revealed that during the timeframe in question, R1 was also occupied with a visitation by an outside individual. Records review further revealed that R1 was consistently observed and/or checked on in 2-hour intervals. Outside sources interviewed did not express concern regarding R1's needs being met or R1 being monitored consistently for assistance. During an unannounced facility visit, LPA directly observed caregivers engaging with residents 1 on 1, and checking on residents in their rooms. LPA directly observed most resident room doors open with their beds being in view from the hallway. The resident in question was unable to be interviewed.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Maria Sano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.