complaint·September 19, 2025

***CONTINUE FROM 9099*** S1 also reported that R1 was encouraged to use pendent for assistance in daily activities in addition to regular check-ins. S3 stated that he always went to R1s room to offer assistance and "passed on notes to the next caregiver on shift". LPA reviewed communication log, check-in schedule, and internal caregiver notes. LPA reviewed staff schedule for the month of March and April. On 4/14, S3 stated that he "found R1 on the floor outside of his room with blood coming from R1's head. S1 stated that "911 was called by the med tech, W1 was notified, and R1 was taken to the hospital immediately". W1 stated that she is unable to provide hospital records and pictures. Review of R1's care plan and staff assignment sheet revealed that R1 was on a total assist with activities of daily living. Allegation: Staff did not refund resident according to the resident’s Admission Agreement- Unsubstantiated Review of R1s payer summary revealed that W1 paid the facility $16998.38 on 04/08/2025. On 04/21 W1 was refunded 10081.67 which included 5081.76 for the the part of the month that R1 was not residing at the facility. The summary also showed that R1 was refunded one time move in fee of $5000. W1 stated that she did receive 10081.67 from the facility. S4 stated that "what we have in the admission agreement is what we follow". LPA reviewed the ledger and the admission agreement for R1. Allegation: Staff mismanaged resident medication - Unsubstantiated Review of R1 record revealed that R1 was at the facility for 18 days. W1 stated that she received a call regarding missing medication. No staff member at the facility could verify that called her regarding missing medication. S2 stated that only 1 over the counter medication was missing. S2 further stated that W1 "called and mentioned that she will bring the over the counter medication to the facility". LPA checked the MAR for R1. No missing medication was marked on R1's MAR. LPA also reviewed a sample of resident's (R2,R3) medications. There was no missing medications reported on R2's and R3's MARs. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** This agency has investigated the above allegations. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.