The investigation consisted of LPA taking tour of entire facility inside and outside, interviews with two (2) staff and one (1) client. LPA reviewed seven (7) staff files, two (2) resident files, took tour of entire facility inside and outside. Reviewed and obtained pertinent documents from both staff and clients.

The investigation revealed. LPA interviewed two (2) staff and two (2) of (2) staff stated that facility has been painted recently in and out and that windows have been worked on and now all open. One (1) resident interviewed could not collaborate the allegation. LPA observed the facility to be in good repair and painted inside and out with fresh paint. The living room had new windows installed. Windows were inspected by LPA and all the windows in facility open and closed during the visit. The bathroom grab bars were painted and fastened properly. Locks were changed on all doors and can lock from the inside. Chemicals were properly stored and locked. There is insufficient evidence to substantiate this allegation.

Allegation: Staff are not adequately trained. It is alleged that staff do not have medication administration handling and other required training.

The investigation revealed: LPA interviewed two (2) staff and two (2) of two (2) staff denied that allegations. One (1) resident interviewed could not collaborate the allegation. LPA reviewed seven(7) staff files and all the staff had up to date training that meets the department’s requirements. There is not enough evidence to substantiate this allegation.

Allegation: Facility failed to ensure that client files are complete, and current records are maintained for each client. It is alleged that client files are missing required documents/forms. The investigation revealed: LPA interviewed two (2) staff and two (2) of two (2) staff denied that allegations. One (1) resident interviewed could not collaborate the allegation. LPA reviewed the two (2) client files and both were complete and in compliance with department regulations at the time of visit. There is not sufficient evidence to substantiate the allegation.

Allegation: Uncleared adults working at facility. It is alleged that there is current staff that are not cleared. The investigation revealed: LPA interviewed two (2) staff and two (2) of two (2) staff denied that allegations. One (1) resident interviewed could not collaborate the allegation. LPA reviewed all staff files and all current staff are fingerprinted, cleared and associated to the facility at the time of visit. There is not sufficient evidence to substantiate the allegation.

Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

The investigation revealed: LPA interviewed two (2) staff and two (2) of two (2) staff denied that allegations. One (1) resident interviewed could not collaborate the allegation. LPA reviewed seven (7) staff files and five (5) of seven (7) staff files had application signed and dated, and in compliance with department regulations. Files of all current staff included ID and all had evidence of being cleared and associated to facility at the time of visit. S3 and S6 were missing Health Screening report. There is sufficient evidence to substantiate the allegation.

Based on LPAs observations and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. Deficiency cited on 9099D