complaint·August 25, 2025

Page 2 Staff are not following physicians’ instructions. - UNSUBSTANTIATED It was reported that resident's physician indicated that the facility needs to do a urine catch on Resident 1 (R1) to track how much R1 is urinating. LPA reviewed R1’s Service Plan dated 01/16/2025 indicates that R1 manages their own medication and independently coordinates their own healthcare appointments. Physicians report states that R1 is able to manage their own medication with assistance from family. LPA reviewed R1’s Over the counter PRN and First Aid Orders which includes Medication / Treatment: Urine collection/C+S if indicated. Instructions: UA and Culture to be collected as needed, for observed symptoms of a UTI. The facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating. R1 stated that they are asked for a urine sample when they are at the hospital, and every time they take a blood test. Resident Care Coordinator stated that R1’s physician has not ordered a urine sample related to output but they do have a standing order in case or symptoms of UTI. It was determined that the facility does not have a physician’s order from R1’s doctor requesting the facility do a urine catch on R1 to track how much R1 is urinating. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Staff did not ensure that resident is provided an adequate amount of water. - UNSUBSTANTIATED It was reported that that per R1’s physician, staff need to encourage R1 to drink water every two hours. R1’s Service Plan dated 01/16/2025 indicates that R1 is independent with all activities of daily living and does not require assistance with meal reminders or feeding support. There is no physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours. On 06/25/2025 LPA observed a hydration station in the common area / dining room that contained large containers of water and lemonade with ice. Resident interviews revealed that the facility has a hydration station and residents help themselves but staff do not offer water unless it is mealtime. Resident Care Coordinator stated that R1 is very capable of drinking water throughout the day. RCC stated the facility has hydration carts located in the front and back of the facility. RCC stated that staff offer residents something to drink 3 or 4 times a day in rounding. It was determined that R1 does not have a physician’s order or notes on file at the facility requesting staff to encourage R1 to drink water every two hours. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. An exit interview was conducted. A copy of the report was provided to facility Executive Director Shay Ewing.