complaint·March 19, 2025

The investigation consisted of the following: On 03/19/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of the Memory Care Unit. Interviews consisted of 5 staff [Staff 1 (S1) to Staff 5 (S5) were interviewed] interviews, 5 resident [Resident 1 (R1) to Resident 5 (R5) were interviewed] interviews, and 7 witness [Witness 1 (W1) to Witness 7 (W7) were interviewed] interviews. Facility records reviewed consisted of Crofton Manor Inn Facility Plan of Operation, Theft and Loss Policy, Employee Roster, Resident Roster, and Resident Contact Sheet. Resident records reviewed consisted of Identification and Emergency Information, Physicians Reports, Unusual Incident Reports (UIRs), Resident Appraisal, Individual Service Plan & Preference, Individual Service Plan (R1, R2, R6, and R7 records were reviewed). The investigation revealed the following: Allegation: “Staff do not ensure adequate care and supervision is being provided”, it is being alleged that the facility does not provide adequate care and supervision for memory care residents. Interviews conducted with R1 to R5 revealed the following: 2 out 5 residents denied the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that care and supervision was not provided. Observations of the memory care unit on 3/19/2025 revealed the following: The department observed caregivers providing care and supervision to memory care residents such as conducting room checks, assisting residents in the bathroom, assisting residents with feeding, and repositioning residents. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff do not safeguard residents personal items”, it is being alleged that a resident goes into other residents rooms and takes their belongings, eats their food and staff does not safeguard residents personal items in the memory care unit. Interviews conducted with R1 to R5 revealed the following: 1 out 5 residents denied the allegation; 1 out of 5 residents agreed with the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that residents’ personal items have gone missing. Observations of the memory care unit on 3/19/2025 revealed the following: The department did not observe residents going into rooms that were not theirs. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: “Staff keep residents door locked”, it is being alleged that staff are locking residents inside their rooms in the memory care unit. Interviews conducted with R1 to R5 revealed the following: 2 out 5 residents denied the allegation and 3 out 5 resident interviews were inconclusive. Interviews conducted with S1 to S5 revealed the following: 5 out of 5 staff denied the allegation. Interviews conducted with W1 to W7 revealed the following: 7 out of 7 witnesses denied the allegation. Records reviewed revealed the following: no UIRs were found indicating that residents have been locked in their rooms. Observations of the memory care unit on 3/19/2025 revealed the following: all the resident rooms had an open door; the department did not observe locked or closed resident doors. Based on interviews, records, and observations this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated No citations were provided. An exit interview was conducted, and a copy of this report was left with the Administrator.