Complaint Investigation Report

It was also determined that food supply on hand and food purchased matched the scheduled items on the facility menu. Interviews revealed adequate food is being distributed to clients in care at this time. Based on interviews, observation, and record review, it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation #2: Facility is in disrepair: LPA conducted facility observation on 12-3-21 and 12-22-21. LPA toured facility inside and out and tested functionality of doors, bathroom faucets, toilets, and showers. LPA also observed common areas, resident bedrooms, and kitchen area. LPA also interviewed three staff and three clients in care. Based on observation and interviews, it is determined that facility toilets, faucets, and doors function properly. Facility was observed by LPA to be clean and sanitary with no foul odors. Facility also contained adequate lighting throughout. Interviews conducted revealed facility has an internal maintenance service to address any as needed repairs. LPA observed a completed maintenance log dated 10/31/21 to 12/24/21. Based on interviews and observations it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation #3: Licensee did not ensure that sufficient direct care staff are at the facility whenever clients are present. LPA conducted interviews with three staff members and three residents. LPA also reviewed facility staffing schedule and actual hours worked. Based on interviews and record reviews it is determined that facility maintains 4 staff on during AM shift, 4 staff on during PM shift, and 2 staff on during night shift. LPA also observed staffing levels consistent with staffing schedules. Interviews revealed clients’ needs are met based on current staffing levels. Based on observations, interviews, and record reviews, it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Based on this investigation and today’s visit, no deficiencies are cited. An exit interview was conducted with Jessica Owens and a copy of this report was left with Jessica.