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32 | Regarding the allegation: Unqualified staff providing care to residents. It was alleged that S2 lacked the skills and competence to provide care and supervision to the residents. To investigate the allegations, LPA conducted interviews with two (2) staff members. LPA’s interview with S2 revealed they are the live-in staff member who cares for the residents and S1 will arrive in the mornings and evenings to assist with medications. When questioned if they could provide information regarding the residents’ diagnosis and needs/services, S2 could not answer. Additionally, upon LPA’s arrival on 4/02/2026, LPA observed S2 to be walking around the neighborhood’s curved sidewalk, away from the facility leaving all three (3) residents alone. Further record review of S2’s file revealed that S2’s First Aid/ Cardiopulmonary Resuscitation (CPR) certification was expired (01/2026). LPA’s interview with S1 revealed they would have to seek a new replacement for S2 due to them lacking the compression needed to fulfill their position. When questioned if they could provide S2’s proof of training via documentation showcasing dates and hours of training completed, S1 could not provide LPA with the information requested but instead a sheet dated 10/11/2025 with topics such as: Resident Personal Right, Elder Abuse and Hand washing and Infection Control. The documentation provided documented the length of training to be “2.5 hours”. When questioned where the remainder of S2’s training hours were reflected via documentation showcasing dates and hours of training completed, again S1 could not provide LPA with the information requested.
Based on interviews, observations and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.
Regarding the allegation: Facility does not have adequate staffing. It was alleged that the facility had failed to provide an appropriate level of supervision to ensure resident’s needs are met. To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S1 revealed they arrive both mornings and evenings to assist with residents’ medications. When questioned if they could provide the LIC 500 Personnel Report showcasing staff and their schedule, S1 could not provide LPA with the information requested. LPA’s interview with S2 confirmed they are the only staff member working. S2 stated they receive, “No Breaks”. Additionally, upon LPA’s arrival on 4/02/2026, LPA observed S2 to be walking around the neighborhood’s curved sidewalk, away from the facility leaving all three (3) residents alone. During LPA’s initial visit, LPA observed R3 to call out for assistance from their room while both S1 and S2 were in the kitchen. LPA observed S1 to tell S2 to go assist R3. During LPA’s physical plant tour, LPA observed R3’s bedroom to not have any auditory alarms to communicate when they need assistance. LPA’s interview with S1 revealed they have not placed such alarms yet but would. (Continue to LIC 9099-C)
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