Staff interviews did not indicate that medications were not being given to residents as prescribed. All resident interviews and those with outside sources corroborated that they received their medications in a timely manner. An attempt for a copy of the Medication Administration Record (MAR) was done, however the facility switched over to a new recording system and are not obligated to retain records after three (3) years.

All staff interviews acknowledge issues with being short staffed, but most do not believe it directly caused resident needs to go unmet. Resident interviews revealed that their needs were being met. File reviews of documents from May 2021 indicate that the average wait time for a call button response was 4 minutes and 39 seconds, facility census was 48 residents, and an average of 4-6 staff members were scheduled per shift.

Interviews with residents, outside sources, and file reviews revealed that the admissions agreement was followed by the Administrator. Concerns discussed in interviews were explicitly listed as excluded responsibilities by the facility as per the Admissions Agreement.

Staff interviews indicate that staff do receive adequate training. Staff were able to recall specific trainings completed, and the thoroughness of the staff training logs when conducting file reviews corroborated that. Furthermore, interviews with residents and their responsible parties did not reveal any concerns about staff being properly trained.

Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Najera to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.