Complaint Investigation Report

Allegation #2: Staff are not properly storing medication. LPA conducted facility tour and observed medication storage area and reviewed additional facility documentation containing photos of medication storage area. LPA observed medication storage area to contain medication stacked in a disorganized manner and used bubble pack medication containers and other items on the floor of the storage cabinet. Based on observation, this allegation is SUBSTANTIATED.

Allegation #3: Facility door has inappropriate locks. LPA conducted facility tour and observed a locking deadbolt mechanism and on front door. LPA also conducted interviews with Assistant Administrator and S1. Based on interviews and observation, it was determined that R1 has a history of exit seeking and deadbolt is locked from the inside to prevent R1 from exit seeking. LPA was unable to open door after it was locked with a key maintained by staff. Based on observation, this allegation is SUBSTANTIATED.

Allegation #4: Facility is in disrepair. LPA conducted facility tour inside and out. LPA observed torn carpeting and drywall on the edges of the top staircase. LPA also observed a loose banister on the top left of the staircase. LPA also conducted interview with Assistant Administrator. Based on observation and interview, this allegation is SUBSTANTIATED.

Allegation #5: Food is not adequately stored. LPA conducted facility tour of kitchen area including refrigerator and non-perishable storage area. LPA observed a left over food item in the refrigerator to be covered without a label and date. LPA observed a bag of flour in the non-perishable storage area exposed and not tightly closed. Based on observation, this allegation is SUBSTANTIATED.

Allegation #6: Facility does not have PPE supplies. LPA conducted facility tour and interview with Assistant Administrator. LPA observed PPE storage area to contain 1 box of masks and 1 box of gloves. Additionally, based on interview, it was revealed that PPE was provided by outside source on 6-9-22, and 30-day supply of PPE was not available at that time. LPA did not observe a 30-day supply of PPE during today's visit. Based on observation and interview, this allegation is SUBSTANTIATED.