Complaint Investigation Report

Based on interviews with 5 residents (R1 to R4), staff are not present at the facility 24 hours, 7 days a week. ADM stops by the facility to cook fresh meals three times a day and leaves after food and medications are served.

ADM/Licensee reported to the facility at 8:15am today and left the facility 9:45am after breakfast. ADM arrived at the facility at 11:45am once LPA Rai called Licensee at 11:15am

During visit, LPM and LPA had to supervise residents while ADM had to leave the facility twice at 1:40PM to pick up ADM’s computer and returned at the facility at 2PM and ADM left at 4:30pm and returned at around 5:30PM to assist with medications at ADM’s RCFE. ADM was the only staff associated at this facility.

LPM and LPA observed 5 residents at the facility and no staff members were present at the facility during visit. Licensee was not initially at facility but later came after all resident interviews were done.

Per ADM/Licensee, Tenant 1 (T-1) will pass medications on behalf of ADM and T1 lives on the facility without background fingerprint clearance or associated to the facility.

Per ADM/Licensee, S2 (husband) used to work at this facility and provide supervision while ADM is out of the facility to run errands such as shopping and supervising at ADM’s RCFE facility. ADM stated that S2 began S2’s employment, on and off, since licensure of the facility. ADM stated that S2 is no longer allowed to work as of 02/24/2023.

Based on LPAs’ observation, interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.