complaint·July 17, 2025

Summary and Post Discharge Plan of care dated 7/5/2024, Identification and Emergency Information, Needs and services plan dated 7/5/2024, Physician's Report dated 7/2/2024. Admissions Agreement dated 7/3/2024, Personal property valuables list dated 7/3/2024 , Staff and Resident rosters for 6/2024 and 4/2025, LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to observations made during the tour of the facility. Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10). The 10 staff members interviewed stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not handled them in a rough manner causing injury. The remaining 7 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, but none could be provided as there were no incidents to report regarding restraining residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not restrained them in any way. The remaining 7 residents were unable to engage in a clear conversation. 3 Allegation: Staff did not provide a safe and comfortable environment for residents LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provides a safe and comfortable environment for residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have provided a safe and comfortable environment . The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA observed that the residents were in a safe and comfortable environment, with no health and safety concerns noted. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provide residents with privacy while assisting with showers and any ADLs requiring privacy. LPA interviewed Residents 1 - 10 (R1–R10) Of the 10 residents, 3 stated that staff provide them with privacy, while the remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA did not observe any residents’ rights being violated. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff have not mismanaged residents’ medication. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff provide them with their medications daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed R1's Medication Administration Records (MARS) and based on LPA's observations and documentation it appeared that R1's medications had been administered as prescribed by their physicians. 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents are not left unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours to address incontinence issues and as needed. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) as needed or when asked and has not been left unattended to for extended periods. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence and (ADLs) assistance from staff members. Continued 7 Allegation: Staff did not provide adequate food service On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that residents are provided adequate food service based on their dietary needs or modified diets. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they receive three meals and snacks daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents being fed and eating a balanced meal for breakfast (hot cereal, eggs, bacon, and toast) and lunch (baked pork chops, cornbread, mashed potatoes, and mixed veggies). On 5/22/2025, LPA toured the kitchen and observed a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served included tuna casserole, green salad, green beans, cornbread, water, juice, and coffee. A menu available for review reflected the meals served. 8 Allegation: Medications are not being stored properly On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that the medication room is locked when not in use. LPA observed residents’ medications stored properly in the medication room, locked in drawers inaccessible to residents. LPA also observed Medication Technicians (MEDTECHS) using their keys to open the medication drawers during a random audit of records/medications. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they were unsure about medications being stored properly, while the remaining 7 residents were unable to engage in a clear conversation. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that staff have not left residents unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours or as needed to address incontinence issues . Continued... LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) /incontinence issues and or as needed in a timely manner. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence assistance from staff members. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated . An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.