Regarding the allegation that staff do not ensure that knives are inaccessible to residents, during unannounced facility visits, LPA observed the locked closet that has the medications and knives. The closet is locked by a keypad on the doorknob which requires a code. An interview with Resident #2 (R2) reported witnessing Resident #1 (R1) opening the door using the code and put a knife in R2’s hand. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Per staff, R1 must have been looking over staff’s shoulders to get the keypad number. Staff reported that all the codes on locked doors were changed after this incident occurred.

Regarding the allegation that staff do not ensure residents receive mail in a timely manner, interviews with residents did not report issues with receiving their mail. Interviews with staff reported collecting the mail every morning, sorting it, and providing it to the appropriate residents. An interview with Outside Source #1 (OS1), who is familiar with the facility and residents, did not report concerns regarding clients not receiving their mail timely.

Regarding the allegation that staff do not provide adequate food service, records reviewed revealed a recent quality assurance inspection by an outside agency noted the facility as compliant in all matters regarding food and meal service. Additionally, during unannounced facility visits, LPA observed adequate amounts of food and did not observe any expired food in fridge or pantry. Interviews with residents did not report any issues with inadequate food service.

Regarding the allegation that staff do not ensure the facility is clean and sanitary, during unannounced facility visits, LPA observations did not raise any cleanliness concerns. An interview with OS1 did not report any concerns regarding the level of cleanliness of the facility. Interviews with staff reported the facility being cleaned on a regular basis. Additionally, interviews with residents did not report any issues with the facility being unclean.

Regarding the allegation that staff do not provide residents with activities, per interviews with residents, there are always fun things to do and residents go out into the community often. Interviews with staff corroborate planned activities. Records reviewed revealed several activities planned for residents throughout the month. Further, an interview with OS1 reported not having any concerns about residents being idle or facility staff not planning activities for residents.

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Regarding the allegation that staff do not ensure the bathroom has hand soap/paper towels, during unannounced facility visits LPA observed more than an adequate amount of paper towels and soap in the bathroom. Interviews with residents did not raise concerns about being without soap or paper towels.

Regarding the allegation that staff make residents clean the facility, OS1 reported residents like to participate in doing chores and they are a part of residents’ outcomes in their Individual Program Plan (IPP). Interviews with the residents corroborated that they like to help with cleaning and do not feel forced to do so. Records reviewed corroborated that completing given tasks are a part of residents’ IPP.

The Department has investigated the above mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated.

An exit interview was conducted with Licensee Cheryl Baum and House Manager Carrie Baum to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.