Complaint·June 1, 2022

Allegation: Staff is sleeping in the common area Based on interview, there is no staff or resident observed any staff sleeping in the common area. Allegation: Staff are not properly trained to care for residents Based on interview and records review, staff complete their training from an off-site building before starting at the facility. Facility used online system for all required staff training except for 16-hours hands on training which is being conducted at the facility. Allegation: Staff do not follow medical orders as required Based on interview and records review, Medical Administration Report (MAR) was completed, meaning the medication was given to R1, staff also documented medication refusal from R1. R1 was admitted into hospice care on 8/12/21 for end of life comfort care and life expectancy was less than six months. It was noted in her hospice records that R1’s family's wishes are for her to be comfortable at home with comfort measures only. They did not want any further aggressive treatment or any life sustaining procedures. On 9/12/2021, R1 was found on the floor, care staff conducted an assessment, reported the fall to Hospice agency and requested an assessment from a hospice nurse. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided. R1 was admitted into hospice care on 8/12/21 for end of life comfort care, life expectancy was less than six months. It was noted in her hospice records that R1’s family's wishes are for her to be comfortable at home with comfort measures only. They did not want any further aggressive treatment or any life sustaining procedures. On 9/12/2021, staff found R1 on floor, R1 had history of falling and the facility developed a fall plan and facility was following it. Staff check vital sign and assessed R1, facility reported the incident to hospice agency and requested for nurse assessment. Hospice agency arrived at the facility and assessed R1. Based on interview and records review, hospice nurse assessed resident and appeared to be asleep and comfortable and did not see any indication of neglect. Hospice nurse stated when she arrived, a facility nurse and caregiver were present in R1’s room checking her vitals. R1 did not have any major injuries and she appeared comfortable. Allegation: Staff is overcharging for services not received Based on records review, signed admission agreement stated that rent will continue to be charged until all personal belongings, clothing, and furnishing have been removed. Based on records review, family emptied the apartment not until Sept. 16, 2021 which was a day after R1’s passing. Based on information gathered, the allegations are unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of this report provided.