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32 | (Continued from LIC9099)
Facility staff were interviewed and consistently reported reporting requirements, including timelines for notifying the Department, responsible parties, and other agencies when appropriate. Staff stated that all incidents are documented immediately and submitted to the Department within the required time frame. The incident reports reviewed were properly addressed. There was no evidence of lack of supervision during the resident to resident incident. The facility staff followed the policy in place regarding resident to resident inappropriate interaction.
Residents interviewed revealed that they feel safe at the facility. There were no complaints of lack of staff from residents. LPA interviewed residents regarding their experiences with staff availability, safety, and communication. Residents reported that they feel safe living at the facility and stated that staff are present, approachable, and responsive. Residents did not report any concerns regarding a lack of staffing or delays in staff response. No resident expressed concerns related to incident reporting or staff oversight.
LPA interviewed outside sources, who confirmed they receive incident notifications from the facility promptly when required. Outside sources reported no issues with communication and described the facility as consistent and proactive when incidents occur. There were no complaints of insufficient staffing or supervision from outside contacts.
LPA reviewed the facility’s incident reports for the period of 8/1/25 through 9/1/25, including incident logs, LIC 624s, internal documentation, and communication records. All unusual incidents were found to have been reported to the Department and other required agencies per regulatory timelines. Reports were complete, included required details, and aligned with internal documentation. Outside sources were informed of the incidents when they occurred with no delays.
Based on interviews, LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
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