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32 | Regarding the allegation that the facility did not provide care and supervision: it was alleged that staff are sleeping while on duty and that C2 gained 50 pounds between March 2020 and July 2021. LPA interviewed AD who denied the allegation. LPA interviewed four staff who denied the allegation and stated that staff only sleep at the facility in the staff bedroom while they are not on duty. LPA interviewed four clients. One client was non-verbal, but three clients denied that staff sleep while on duty and reported no issues with the quality of care provided or the food at the facility. Regarding C2’s weight, AD stated that C2 was on a special diet, the facility followed the diet, and C2 lost weight at the facility. LPA reviewed C2’s Weekly Menu which shows the special diet the facility created to help C2 with their weight. LPA reviewed C2’s Physician’s Report dated March 17, 2020 which states C2 weighed 211 pounds on March 17, 2020 and C2’s Weight Records from May 10, 2021 to July 2, 2021 which indicate C2 weighed 249 pounds on May 10, 2021 and 242 pounds on July 2, 2021. However, AD reported that C2 would go to stay with a family member for long periods of time, would gain weight during these stays, and would report eating unhealthy food during these stays after returning to the facility. LPA reviewed C2’s Daily Care Notes for June 2021 which document C2’s food intake and corroborate that the facility was following C2’s diet while C2 was at the facility. The information obtained regarding the reason for C2’s weight gain is conflicting.
Regarding the allegation that the facility does not provide activities: it was alleged staff do not provide activities or walks to clients and C2 mostly stayed in their room while at the facility. LPA interviewed AD who stated the facility has an activity coordinator who organizes activities which include both indoor and outdoor activities. LPA interviewed four staff who described the activities which include walks, outings to parks, recreation centers, stores, and festivals and stated that walks are daily, trips to the recreation center are multiple times a week, and one client is taken on an outing each day. LPA interviewed four clients. One client was non-verbal, but three clients corroborated that the facility has a variety of activities and activities are available every day to clients who choose to participate. Regarding C2, staff reported that they offered C2 walks daily and other activities and sometimes C2 would join in and other times they would not. LPA reviewed C2’s Daily Care Notes for June 2021, C2’s Quarterly Reviews for January 2021 and June 2021, the facility’s Activity Calendar for September 2021 and August 2021, and photographs of outings which demonstrate outings and activities in which C2 participated. The information obtained is conflicting.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegation are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. |