complaint·October 23, 2025

During today’s visit, the LPA conducted a brief physical plant tour and delivered findings for the above allegation between 01:28 PM. and 02:50 PM. The allegation of “Resident was admitted to hospice without consent” alleges that Resident #1 (R1) was transferred to a Hospice company without their or their Durable Power of Attorney (DPOA)’s consent. LPA reviewed R1’s file and observed hospice admission paperwork for the Hospice company in question. LPA observed R1’s name and a signature on the admission documents. LPA interviewed R1 and provided them the document for review. R1 confirmed that the signature and the initials on the document did not match their own. LPA interviewed DPOA who confirmed that they did not give consent for R1 to be enrolled in the Hospice company. LPA interviewed staff #1 (S1), the facility Administrator, and the Assistant Administrator. All staff interviewed denied requesting the transfer of R1 onto the Hospice company but were unsure why R1 was enrolled with the company. Based on interviews with witness #1 (W1) LPA confirmed that due to R1’s condition, R1 was mentally unable to consent to signing up for hospice care at the time they were enrolled with the Hospice company. LPA confirmed that at the time R1 was enrolled with the Hospice company, R1 was under the care and supervision of the facility. LPA reviewed documentation from the Department of Health & Human Services which stated that as of 04/07/2025 the Hospice company has had their Medicare provider agreement involuntarily terminated and is no longer operating. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Resident was admitted to hospice without consent.” Therefore, the allegation is deemed Substantiated at this time. The Assistant Administrator was unable to come to the facility during today's visit but has designated S1 to sign this report on their behalf. This report was read to the Assistant Administrator via telephone call. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted. During today’s visit, the LPA conducted a brief physical plant tour and delivered findings for the above allegations between 01:28 PM. and 02:50 PM. The allegation of “Staff make residents stay in bed all day” alleges that facility staff do not assist residents with leaving their beds and require that they remain in bed throughout the day. LPA interviewed five (5) residents of the facility. Residents interviewed had no concerns about staff not assisting them in transferring from their bed. Additionally, no residents interviewed stated that they are required by staff to remain in bed during the day. Resident #1 (R1) stated that they have a walker in their room and ask staff for assistance with utilizing the device but have been asked to build leg strength before attempting to use the walker. Interviews with R1’s Durable Power of Attorney (DPOA), Staff #1 (S1), and R1 revealed that during early 2025 R1 was not physically well enough to move about the facility with significant staff assistance. S1 stated that they attempted to move R1 from their bed to the dining table for meals but R1 was unwilling and unable to move so meal service to R1’s bed was provided until R1 recovered. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff make residents stay in bed all day.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff falsified resident records” alleges that R1’s records contained falsified signatures. LPA reviewed R1’s file and observed R1’s physician report to be signed by an emergency room doctor. LPA contacted the phone number listed, and the representative was able to confirm that the doctor did work in their emergency room. All other required documentation located in R1’s file appeared to be signed by DPOA and a facility representative. LPA observed R1’s hospice admission paperwork for Hospice. LPA observed a signature on the admission document but interviews with R1 and DPOA revealed that this signature did not match R1’s signature. LPA interviewed S1, the Administrator, and the assistant Administrator, all of whom denied falsifying the signature. Although the signature on R1’s hospice paperwork was confirmed to be falsified there is insufficient evidence to prove facility culpability as it remains unclear who falsified the signature. LPA reviewed documentation from the Department of Health & Human Services which stated that as of 04/07/2025 the Hospice company has had their Medicare provider agreement involuntarily terminated and is no longer operating. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff falsified resident records.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The Assistant Administrator was unable to come to the facility during today's visit but has designated S1 to sign this report on their behalf. This report was read to the Assistant Administrator via telephone call. Exit interview was conducted and a copy of the report was provided.