complaint·August 10, 2023

Allegation: Facility does not have awake staff at night. Based on interviews with S1 and S2, they respond to residents when residents call for help. According to S2, S2 wakes up every hour and checks on the residents. AGPA and LPA attempted to interview two residents (2) but were unable to obtain additional information. Allegation: Facility did not fulfill reporting requirements. Based on information obtained from complainant, R1 fell out of her wheelchair. However, S1 and S2 denied of the incident. AGPA reviewed discharged notes from the hospital and it did not indicate that R1 fell out of her wheel chair. Due to conflicting information, AGPA was unable to prove or disprove allegation. Allegation: Facility did not seek resident timely medical attention. Based on record review of staff daily notes, on 3/14/23, S2 observed R1 had phlegm and was congested. S2 notified R1's responsible party and suggested R1 is to be seen by the doctor. According to the staff notes, R1 was not exhibiting shortness of breath. R1 was admitted to the hospital by R1's responsible party Allegation: Facility did not ensure that resident received sufficient nourishment while in care. Based on information obtained by complainant, due to R1 being over medicated from drugs, R1 was not eating. AGPA reviewed appraisal and physician's report and both records indicated R1 is able to feed herself. However, S1 and S2 stated R1 needed assistance. AGPA obtained a copy of an order from R1's speech therapist that puree diet with honey thick liquids to be initiated on 3/2/22. Resident's fee increase was not clearly specified. Based on record review, AGPA obtained a copy of the notification and observed that R1 was given a 60 day notice of the increase due to change in condition. However, R1 was not charged of the new rate because R1 had moved out of the facility. ***REPORT CONTINUES ON 9099C*** Facility failed to issue a proper refund. Based on record review of Admission Agreement, residents/responsible parties are to provide a 30-day notice or rates will continue. AGPA discovered when R1 was admitted to the hospital by R1's responsible party on 3/14/23, R1 never returned to the facility and facility was not provided a 30-day notice. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted with Administrator and a copy of report provided.