On 02/23/23 at 10:00am, LPA interviewed S1. S1 denied the allegation that staff do not dispense residents’ medication as prescribed. S1 stated that all of the med-techs have to adhere to what the doctor orders are and when the medication should be given to the resident. And at no time have they not adhered to those orders. Additionally, S1 stated that there are Medication Administration Records that will corroborate this fact.

On 02/23/23, LPA interviewed S2-S6 about the allegation that staff do not dispense residents’ medication as prescribed. S2-S6 all denied the allegation and asserted that they are following what the doctor has prescribed for each of the residents. And that all medications given with the dates and times are noted in the Medication Administration Record.

On 02/23/23, LPA interviewed R1-R6 about the allegation that staff do not dispense residents’ medication as prescribed. And 6 of 6 residents denied the allegation and confirmed that they are receiving their medication as prescribed.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not dispense residents’ medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #2: Unqualified staff dispensing medication

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Unqualified staff are dispensing medication. S1 stated that all of the med-techs are trained and qualified to dispense medication and certified that all training was up to date. LPA verified by certificates on file.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Unqualified staff are dispensing medication. S2-S6 all denied the allegation and stated they were trained and qualified to dispense medication and have certificates to prove it.

On 02/23/23, LPA interviewed R1-R6 about the allegation Unqualified staff are dispensing medication. 6of 6 residents stated that as far as they knew all of the med-techs were qualified to dispense their medication and had no reason to believe otherwise.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Unqualified staff are dispensing medication. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff do not relay residents request to see doctor. S1 stated that all residents are given the opportunity to see their doctor, talk to their doctor, and visit their doctor. No one in the facility is denying any resident the right to see his/her primary care physician.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not relay residents request to see doctor. S2-S6 all denied the allegation and stated overwhelmingly that the residents’ rights are never violated and if they need to see their doctor, it will be arranged.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff do not relay residents request to see doctor. LPA asked all six (6) residents if they were denied the right to see or speak with their doctor. 6 of 6 residents all denied that the allegation was true. Each resident stated that they were not denied access to see their doctor.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not relay residents request to see doctor. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #4: Staff are not ensuring resident's bathroom is cleaned

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff are not ensuring resident's bathroom is cleaned. S1 stated that there is daily cleaning done for the residents’ room, bathroom, as well as the general facility. S1 also stated that some days some of the residents don’t allow any one in their rooms to clean it for whatever reason. But that on the whole the facility is cleaned daily.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff are not ensuring resident's bathroom is cleaned. S2-S6 all denied the allegation and asserted that the bathrooms are cleaned daily by housekeeping.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff are not ensuring resident's bathroom is cleaned. LPA interviewed six residents and of the six that were interviewed the majority stated that they did not have an issue with staff not cleaning their room or bathroom. They all stated that they were satisfied with the housekeeping of the facility.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff are not ensuring resident's bathroom is cleaned. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff do not respond to residents call button. S1 stated that all staff are trained to answer calls from the residents once they push the call button. Once they do, the staff responds and sends someone to attend to their needs, if needed. And that at no time are the residents’ calls ignored.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not respond to residents call button. S2-S6 all denied the allegation and stated that the residents’ calls are never ignored and that they make every effort to answer all concerns.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff do not respond to residents call button. Residents 1-6 that were interviewed, with a majority vote, stated that whenever they push the call-button a staff always responds and follows up to see if they are okay.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not respond to residents call button. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #6: Facility does not have gloves for handling residents’ hygiene needs.

On 02/23/23, LPA interviewed S1. S1 denied the allegation that the Facility does not have gloves for handling residents’ hygiene needs. S1 stated that the facility has at least a 90-day supply of PPE’s. And in that supply, there is more than enough gloves to handle the resident’s hygiene issues. Moreover, each staff has access to all PPE supplies. So, says S1, there should not be an issue with handling the resident’s hygiene needs.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Facility does not have gloves for handling residents’ hygiene needs. 5 of 5 staff that were interviewed all corroborated that the facility has enough gloves to handle the residents’ hygiene needs in the event that there are situations that call for gloves.

On 02/23/23, LPA interviewed R1-R6 about the allegation Facility does not have gloves for handling residents’ hygiene needs. While conducting interviews with the residents 5 of 6 residents corroborated that the staff had gloves and used them when necessary.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Facility does not have gloves for handling residents’ hygiene needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that the Staff do not aide residents with their hygiene needs. S1 stated that all caregivers do aide those residents that need assistance with their hygiene needs. And has not heard of any complaints to the contrary. Besides, S1 states, it’s their job to do so.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not aide residents with their hygiene needs. Each staff, S2-S6, all denied this allegation and stated it was false. Some stated that not all of the residents need help with their hygiene needs but of those that do, no one is not given assistance when needed.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff do not aide residents with their hygiene needs. 6 of 6 residents deny this allegation and state that the staff are responsive to their needs and are satisfied with the service.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not aide residents with their hygiene needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #8: Staff do not serve nutritious meals.

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff do not serve nutritious meals. S1 states that there is a meal plan in place that considers the nutrition aspect of all the residents in the facility. And every resident has access to nutritious meals. S1 provided the LPA with meal plans that prove that nutritious meals are being served to its residents.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not serve nutritious meals. S2-S6 all deny this allegation and also point to the meal plan showing that nutritious meals are being served daily.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff do not serve nutritious meals. 6 of 6 residents interviewed all corroborate that the facility is preparing nutritious meals for the residents. And that they are satisfied with the meal service.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not serve nutritious meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff do not prevent residents from fighting. S1 states that anytime there is an issue in the facility, staff are always on hand to mediate and calm things between the residents. S1 states that there are times when residents get angry with each other but that at no time are the staff never there to prevent actual fights in the facility.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not prevent residents from fighting. S2-S6 all deny the allegation and assert that they are always there to prevent any violence that may occur between the residents.

On 02/23/23, LPA interviewed R1-R6 about the allegation Staff do not prevent residents from fighting. R1-R6 all deny that this allegation is true. Further, they state that the staff is always there and that they feel safe in the facility.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not prevent residents from fighting. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #10: Administrator is not responding to resident's representative

On 02/23/23, LPA interviewed S1. S1 denied the allegation that the Administrator is not responding to resident's representative. S1 states that anytime any of the residents’ representatives have questions, issues, or concerns S1s door is always open; and at no time does S1 not respond to a residents’ representative. Additionally, S1 states that S1 is here most days and is not sure why someone would suggest otherwise.

On 02/23/23, LPA interviewed S2-S6 about the allegation that the Administrator is not responding to resident's representative. S2-S6 all deny that they know of anyone that the administrator has ignored or not responded to.

On 02/23/23, LPA interviewed R1-R6 about the allegation that the Administrator is not responding to resident's representative. 6 of 6 all deny that they know of any instance where the administrator has not responded to a resident’s representative or that they have any personal experience with this allegation.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Administrator is not responding to resident's representative. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Residents are smoking in their room. S1 states that all residents know that they are not allowed to smoke in their rooms and that there is a special place outside of the facility where they can smoke if they are so inclined to do so. And if they are caught doing so, they are reprimanded and reminded of the house rules.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Residents are smoking in their room. S2-S6 all deny that they have knowledge of any residents smoking in their room. And insist that all the residents know that that is not allowed, and that there is a patio area for those who choose to smoke.

On 02/23/23, LPA interviewed R1-R6 about the allegation that Residents are smoking in their room. 6 of 6 residents that were interviewed all deny that they have any knowledge of anyone smoking in their rooms.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Residents are smoking in their room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #12: Staff speak inappropriately to a resident in care

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff speak inappropriately to a resident in care.

S1 states that to his knowledge, none of his staff has spoken to any of the residents’ inappropriately. And that no one has complained to S1.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff speak inappropriately to a resident in care. S2-S6 all deny that any of the staff speaks to the residents in a manner that is disrespectful or inappropriately. And of the six that were interviewed none of them reported that any of the residents made their concerns known to them.

On 02/23/23, LPA interviewed R1-R6 about the allegation that Staff speak inappropriately to a resident in care. 6 of 6 residents interviewed, denied that they have been spoken to inappropriately or know of any other resident that has. And said that the staff has always spoke to them with respect.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff speak inappropriately to a resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that Staff do not ensure serving ware is clean. S1 states that housekeeping makes sure that the facilities silverware is always cleaned after each meal service provided to the residents. LPA inspected the kitchen and dining area and did not observe any deficiencies.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Staff do not ensure serving ware is clean. S2-S6 all deny that the serving ware is anything but clean at all times.

On 02/23/23, LPA interviewed R1-R6 about the allegation that Staff do not ensure serving ware is clean. 6 of 6 residents deny that the serving ware is dirty. All state that they have never had an issue with the cleanliness of the serving ware.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff do not ensure serving ware is clean. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Regarding allegation #14: Facility carpet is dirty

On 02/23/23, LPA interviewed S1. S1 denied the allegation that the Facility carpet is dirty. S1 acknowledges that some parts of the facilities carpet are old, but that at no time is it ever dirty for an extended period of time. S1 states that housekeeping cleans throughout the day and vacuums as needed.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Facility carpet is dirty. S2-S6 all deny that the carpet is dirty. A majority say it may look old, but it is never dirty.

On 02/23/23, LPA interviewed R1-R6 about the allegation that Facility carpet is dirty. 6 of 6 residents deny that the carpet is dirty. They all corroborate that housekeeping cleans the carpet daily.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Facility carpet is dirty. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Report continued on LIC9099-C

On 02/23/23, LPA interviewed S1. S1 denied the allegation that the Facility is malodorous. S1 states that housekeeping, caregivers, and staff all try to keep the facility smelling as fresh as it can by making sure the residents hygiene needs are met; the rooms and bathrooms are cleaned daily; and that the general cleanliness of the facility is maintained.

On 02/23/23, LPA interviewed S2-S6 about the allegation that Facility is malodorous. S2-S6 all deny that the facility is ever malodorous. They further state that housekeeping is always cleaning and sanitizing the rooms, kitchen, bathrooms, and the entire facility daily.

On 02/23/23, LPA interviewed R1-R6 about the allegation that Facility is malodorous. 6 of 6 residents all deny that the facility is malodorous. They all corroborate that housekeeping is cleaning throughout the day to prevent any odors from becoming prevalent in the facility.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Facility is malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies were cited.

An exit interview has been conducted and a copy of the Complaint Report provided to Administrator, Melissa Christopher.