complaint·June 3, 2025

Allegation: Facility staff do not maintain documentation of resident(s) records. It is alleged that facility staff do not maintain documentation of resident records. Regarding this allegation it is reported that Administrator retained and admitted residents into the facility without proper documentation. LPAs interviewed Administrator who admitted to accepting Resident #1 (R1) on 05/26/25, however Administrator stated that they were within the seven (7) days allotted to obtain a signed and finalized Admission Agreement. LPAs inquired on the rest of the documents required for each resident file and Administrator stated that they were not able to complete a file for R1 as R1 was admitted to the hospital the following day on 05/27/25. Administrator admitted to not having a medical assessment for R1 prior to admitting R1 as a resident in the facility. LPAs reviewed resident files and discovered that all documents that are required were in three (3) out of three (3) current resident files. Interviews with Staff #1 (S1) revealed that they are not involved in anything pertaining to documents, they simply care for the residents. Therefore, based on file reviews and interviews, this allegation is deemed substantiated. Citation issued. Appeal rights discussed and provided. Exit interview conducted and a copy of report given to Administrator. Allegation: Facility placed resident on hospice without proper consent. It is alleged that facility placed resident on hospice care without proper consent. Regarding this allegation it is reported that Resident #1 (R1) was placed on hospice, which was later revoked, without meeting the criteria for terminal illness. It is also reported that it is unclear as to who authorized hospice services or if a proper diagnosis was established. Interview with Administrator revealed that they had no knowledge of R1 being on hospice or needing hospice services. Administrator stated that R1 was admitted to the facility on 05/26/25 and was in the facility for less than 24 hours before emergency services were called for R1 and as a result R1 was admitted to the hospital where they are still under care. LPA Casillas contacted alleged hospice agency, Superb Hospice Inc., and they were able to confirm that R1 was on hospice care with from 01/30/2025 to 05/07/25. This places R1 on hospice for dates prior to being admitted to the facility. Therefore, based on interviews this allegation is deemed unsubstantiated. Exit interview conducted and copy of report was provided to Administrator.