On 05/19/23, LPA interviewed R1-R10 about the allegation that Staff are abusing residents in care. And 10 of 10 residents denied the allegation and confirmed that they are not being abused or mistreated by staff.

Based on interviews conducted there is insufficient evidence to support the allegation: Staff are abusing residents 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 allegation is Unsubstantiated.

Regarding allegation #2: Staff does not provide a care plan for residents during pre-admissions.

On 05/19/23, LPA interviewed S1. S1 denied the allegation that Staff does not provide a care plan for residents during pre-admissions. S1 stated that all future residents are provided a care plan during the pre-admission stage. LPA asked for a random sampling of ten (10) resident files to verify that each file has a pre-admission care plan. LPA observed all ten (10) files and each file contained a pre-admission care plan.

On 05/19/23, LPA interviewed S2-S6 about the allegation that Staff does not provide a care plan for residents during pre-admissions. S2-S6 all denied the allegation and stated that before any admission to the facility is completed there is a pre-admission care plan for each prospective resident, and it is kept in each resident’s file.

Based on interviews with staff and records reviewed, there is insufficient evidence to support the allegation: Staff does not provide a care plan for residents during pre-admissions. 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 05/19/23, LPA interviewed S1. S1 denied the allegation that Staff does not ensure resident's records are up to date. S1 stated that anytime there is a change in the residents’ condition, medication change, or whenever there is a new physicians report, the residents’ files are updated.

On 05/19/23, LPA interviewed S2-S6 about the allegation that Staff does not ensure resident's records are up to date. S2-S6 all denied the allegation and stated that anytime that there is new information that concerns the resident, their files are updated with the new information such as when they go to the doctor, a change in their behavior, or medication change.

Based on interviews with staff and records reviewed, there is insufficient evidence to support the allegation: Staff does not ensure resident's records are up to date. 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 unable to communicate with residents due to language barrier.

On 05/19/23, LPA interviewed S1. S1 denied the allegation that Staff are unable to communicate with residents due to language barrier. S1 stated that all the staff and residents can communicate effectively with each other. Everyone in the facility speaks English, staff, and residents alike. Some residents speak several languages but there has not been an issue with language barriers.

On 05/19/23, LPA interviewed S2-S6 about the allegation that Staff are unable to communicate with residents due to language barrier. S2-S6 all denied the allegation and stated that there has never been an issue with communication with the residents. The also stated that everyone in the facility speaks English and so does the residents.

On 05/19/23, LPA interviewed R1-R10 about the allegation that Staff are unable to communicate with residents due to language barrier. 10 of 10 residents denied the allegation and confirmed that they can communicate effectively with the staff. They all verified that they speak English and everyone that they have caring for them speaks English too. They did not verify that there was a problem with a language barrier in the facility.

Based on interviews conducted there is insufficient evidence to support the allegation: Staff are unable to communicate with residents due to language barrier. 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 allegation is Unsubstantiated.

Report continued on LIC9099-C

On 05/19/23, LPA interviewed S1. S1 denied the allegation that Staff does not safeguard resident's personal belongings. S1 stated that all residents are given a form upon entry called safeguards for property/valuables, and it lists in detail what items the residents have. Additionally, when the residents are not in their rooms, their door is locked to safeguard their valuables. LPA observed that all files reviewed there was an itemized list of the residents’ belongings in their files.

On 05/19/23, LPA interviewed S2-S6 about the allegation that Staff does not safeguard resident's personal belongings. All staff denied the allegation and confirmed that the residents’ belongings are safeguarded by locking their room doors when the residents are away, and they ensure that all resident items are itemized and placed in their folders for review. LPA observed that all files reviewed there was an itemized list of the residents’ belongings in their files.

On 05/19/23, LPA interviewed R1-R10 about the allegation that Staff does not safeguard resident's personal belongings. 10 of 10 residents denied the allegation and confirmed that they do not have an issue with theft. They feel safe in the facility and feel their belongings are sufficiently safeguarded by the staff. LPA observed that all files reviewed there was an itemized list of the residents’ belongings in their files.

Based on interviews conducted, and records review of their files there is insufficient evidence to support the allegation: Staff does not safeguard resident's personal belongings. 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 allegation is Unsubstantiated.

Regarding allegation #6: Facility administrator does not work adequate hours to operate facility.

On 05/19/23, LPA interviewed S1. S1 denied the allegation that Facility administrator does not work adequate hours to operate facility. S1 stated that most weeks S1 works forty (40) hours or more in the facility. LPA observed that S1 is scheduled Monday through Friday from 9:30am-5:30pm.

On 05/19/23, LPA interviewed S2-S6 about the allegation that Facility administrator does not work adequate hours to operate facility. All staff interviewed verified that S1 is in the facility from Monday through Friday and works forty hours or more per week. Additionally, they noted that S1 is available if needed on off days.

Based on interviews conducted, and records reviewed there is insufficient evidence to support the allegation: Facility administrator does not work adequate hours to operate facility. 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 allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the report was given to Executive Director, Jodi Kanowitz.