complaint·November 6, 2025

It should be noted that Resident R1 passed away on 08/05/25. Hospice chart was reviewed in regards to Resident R1. Staff S1-S3 were interviewed. In regards to the allegation Staff admitted a resident with a prohibited health condition, based on interviews conducted and information gathered it was revealed by family member of Resident R1 that there was never wrong doing by the facility and they did a good job providing care. Stated the complaint is with the Hospice agency. R1 was admitted to the facility on 7/9/23 with hospice services for the gastrostomy (G) tube. Per the administrator and facility staff, R1 is provided food and medications through the G tube. Interview with Assistant Administrator who stated that staff are trained on how to assist the resident on the g-tube. They only give the formula via g-tube (about 5 cartons a day) and then flush it after the feeding to clean the tube. The staff do not replace the dressing. Stated that hospice nurse trained them on what to do and gave instructions to the staff in the beginning. (LPA observed Staff Training Certificates in regards to G-Tube Training). Administrator stated they have a Hospice Care Plan regarding Resident R1. Stated that Hospice supervised staff regarding the G-Tube. If any emergency issues Hospice is called immediately. Staff S1-S3 stated that they all had training regarding G-Tube Care. Said the G-Tube for Resident R1 would clog and as instructed they would try to flush it with water and if still clogged they call Hospice immediately. Hospice Visit Notes state on 10/29/24 G-Tube cleared and changed with new dressing. On 11/02/24 G-Tube clogged. 11/04/24- Medical doctor aware of G-Tube replacement. 11/26/24 g-tube not working. Can not aspirate or flush. Will follow up. On 12/03/24 G Tube dressing changed. G Tube clogged. Follow Up on G-Tube replacement. Interviews with Resident's R2 and R3 both stated staff treat them well and they are getting great care and staff will assist them with whatever they may need assistance with. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff mishandled a resident's medication, based on interviews conducted and information gathered it was revealed by the family member of Resident R1 that staff did a good job taking care of R1. Said he was satisfied with R1 being fed and given medications. Stated his issue is with Hospice Agency and not the facility. Staff S1- S3 stated that staff will give meds through the tube. When it gets clogged, they were instructed to put some warm water on syringe and then flush it. If the tube has been clogging the hospice nurse is made aware of it and will assist Resident R1. Administrator stated that staff all had in-service G-Tube training. Hospice supervised staff on feeding and medication administered. If emergency will call Hospice immediately. Assistant Administrator stated that Resident R1's family member had talked to her about filing a complaint on the hospice agency. Also stated that the staff are trained on how to assist the resident on the g-tube. They only give the formula via g-tube (about 5 cartons a day) and then flush it after the feeding to clean the tube. The staff do not replace the dressing. Stated that the Hospice nurse taught them what to do and gave instructions to the staff in the beginning. Hospice Visit Notes state on 10/29/24 G-Tube cleared and changed with new dressing. On 11/02/24 G-Tube clogged. 11/04/24- Medical doctor aware of G-Tube replacement. 11/26/24 G-tube not working. Can not aspirate or flush. Will follow up. On 12/03/24 G Tube dressing changed. G Tube clogged. Follow Up on G-Tube replacement. Interviews with Resident's R2 and R3 both stated staff treat them well and they are getting great care and staff will assist them with whatever they may need assistance with including medication and meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not ensure a resident was properly fed, based on interviews conducted and information gathered it was revealed by family member of Resident R1 that there was never wrong doing by the facility and they did a good job providing care. Stated the complaint is with the Hospice agency. Also stated that he was here often at the facility and Resident R1 was always fed and administered medication properly. Administrator stated that they follow the care plan for Resident R1 since using a G-tube. Staff do not change the dressing. They are instructed to notify the hospice agency if the dressing is soiled or has a smell. They are only feeding the formula through the G-tube and flushing/cleaning it right after. Assistant Administrator stated that staff are trained on how to assist the resident on the G-tube. They only give the formula via G-tube (about 5 cartons a day) and then flush it after the feeding to clean the tube. The staff do not replace the dressing. Stated that the Hospice nurse trained them on feeding. Staff S1-S3 stated they check Resident R1's G- tube every time to see if it is ok. The hospice nurse had instructed staff what to do and how to properly clean the tube. Stated they put the milk in the bag and when the feeding is done, they add water to flush it out and remove the tube for cleaning. Hospice Visit Notes state on 10/29/24 G-Tube cleared and changed with new dressing. On 11/02/24 G-Tube clogged. 11/04/24- Medical doctor aware of G-Tube replacement. 11/26/24 G-tube not working. Can not aspirate or flush. Will follow up. On 12/03/24 G Tube dressing changed. G Tube clogged. Follow Up on G-Tube replacement. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.