complaint·April 4, 2025

The investigation consisted of the following: On 04/04/2025, a facility tour was conducted, records were reviewed, and interviews were conducted. The facility tour consisted of Resident 1’s (R1s) room. Interviews consisted of 3 staff interviews [Staff 1 (S1) to Staff 3 (S3) were interviewed] and 1 resident interviews (R1 was interviewed). Facility records reviewed consisted of Personnel Report dated 01/2025, Register of Facility Residents dated 01/01/2025, Pest Control documents from 01/2025 to 03/2025. Resident 1 (R1) records reviewed consisted of Admission Agreement dated 01/01/2024, Physicians Report dated 06/13/2024, Appraisal & Needs Services Plan dated 01/28/2025, pictures of his room dated 3/20/2024, Record of Resident’s Safeguard Cash Resources for the year of 2025, etc. The investigation revealed the following: Allegation: “Financial Abuse to resident”, it is being alleged that the facility is financially abusing R1. Interview conducted with the Administrator (S1) revealed the following: S1 denied the allegation. Interview conducted with R1 revealed the following: R1 denied the allegation. Records reviewed of R1’s Record of Resident’s Safeguard Cash Resources for the year of 2025 revealed the following: it depicts that R1 has been receiving their money and each entry has a staff signature and R1’s signature. Based on the 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 are not ensuring that facility is free of pest”, it is being alleged that R1’s room has maggots, cockroaches, and flies. Observation on 04/04/2025 of R1’s room revealed the following: the department did not observe maggots, live cockroaches, and flies. Records reviewed of the Pest Control documents from 01/2025 to 03/2025 revealed the following: the Pest Control Company comes to the facility 4 times per month to 3 times per month, furthermore, R1’s room was fumigated on 02/07/2025, 02/25/2025, and 03/20/2025. Interview conducted with R1 revealed the following: R1 denied the allegation. Interviews conducted with S1 to S3 revealed the following: S1 indicated that R1 had been placed in 51/50 hold and during that time the facility deep cleaned his room, furthermore, S2 and S3 corroborated with S1’s story. Moreover, S1 to S3 indicated that as of right now R1’s room does not have maggots, flies, and roaches. Based on the 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 are not ensuring residents are provided a safe environment”, it is being alleged that R1’s room is unsafe because they have a heather on their bed and staff does nothing to ensure that R1 has a safe environment. Observations on 04/04/2025 of R1’s room revealed the following: the department observed a heather on R1’s bed. Interview conducted with R1 revealed the following: R1 indicated that staff have informed him to remove the heater from their bed, but they do not feel that it is danger to place the heater on the bed, moreover, they get annoyed when staff moves their heater to the floor. Interviews conducted with S1 to S3 revealed the following: 3 out 3 staff denied the allegation, 2 out 3 staff indicated that they have talked to R1 about placing the heater on the floor, 2 out 3 staff indicated that they have moved the heater to the floor. Based on the interviews 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.