complaint·November 26, 2025

Regarding the allegation: Staff signed POLST for resident who cannot consent. It was alleged that the Administrator (S1) had signed resident’s (R1) Physician Orders for Life-Sustaining Treatment (POLST) without their consent. To investigate the allegation, LPA conducted interview with S1 where it was revealed that R1 upon admission to the facility did not have any next of kin or authorized legal representative. When questioned as to why they signed R1’s POLST, S1 denied signing the document. Per S1 the signatures did not match and proceeded to showcase paperwork from R1's file comparing their signature. LPA observed S1’s signature not to match the one shown on R1’s POSLT documentation. During LPA’s record review, LPA conducted a review of six (6) residents on Hospice where it was shown that S1 has not signed any of their consent forms or POSLT. Further record review showcased that S1 had not become the Administrator until 5/12/2025 which revealed discrepancy with R1’s POLST documentation where S1 was listed as the Administrator dated 12/23/2024. Based on Interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff signed resident up/ signed paperwork for Hospice without consent of resident. It was alleged that S1 had signed R1’s consent forms for Hospice without their knowledge or ability to consent. To investigate the allegation, LPA conducted an interview with one (1) staff member. LPA’s interview with S1 revealed that they did not sign R1’s Hospice documentation. Per S1, their signature had been done so fraudulently and without their knowledge nor consent. LPA’s review of S1’s signature compared to those documented on R1’s Hospice “Informed Consent” forms were observed to not match. Further record review of R1’s file showcased that the hospital had placed an order to have R1 admitted into Hospice on 12/23/2024. Further record review revealed that R1 was under an order of “Bio Ethics” by the hospital due to their medical diagnosis and lack of family/friend’s involvement; which resulted in the hospital becoming the designated decision maker of their medical treatments. Based on Interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.