Inspector’s narrative
What the inspector wrote
Staff mismanaged resident's medication.
It was reported that the client has been refusing medications at times. Facility staff attempt to administer medication up to three (3) times, and if the client continues to refuse, they discontinue further attempts. Concern was raised that Resident 1 (R1) may not be receiving prescribed medications, including PRNs, on a consistent schedule. On 01/10/2025, LPA conducted an interview with the Wellness Director (WD), who stated that R1 occasionally refuses medication and that, per policy, staff make three (3) attempts and notify R1’s physician and family of refusals. Additional interviews with the Executive Director (ED) and two (2) MedTechs on 09/30/2025 confirmed that staff follow the facility’s medication policy and procedures when a resident refuses medication. LPA reviewed R1’s Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR), which showed refusals were accurately documented and that notifications to R1’s physician and family were made. Facility medication policy specifies that staff are trained to make multiple attempts and record all refusals. R1 was also interviewed and confirmed that staff consistently offer medications multiple times before documenting refusals.
Based on interviews, record review, and policy examination, there is insufficient evidence to support the allegation that staff mismanaged R1’s medication. Documentation shows staff followed policy and communicated refusals appropriately. Therefore, the allegation is deemed
unsubstantiated
at this time.
Staff did not ensure resident was kept clean
It was reported that Resident 1 (R1) was not being properly cleaned during incontinence care, with fecal matter observed on their person. To investigate, LPA conducted interviews and reviewed facility records.
Interview with WD denied the allegation, stating that residents, including R1, are checked every two (2) hours or as needed for incontinence care. WD further reported that R1 occasionally refuses care. Furthermore, LPA observed that the facility internal notes documented R1 refused incontinence care on 12/21/2024 at 6:40 AM and again at 3:00 PM. Moreover, during the initial visit, R1 was observed to be clean, well-groomed, and free of odor. R1 reported that their incontinence needs are met and that they had no concerns. R1’s Physician’s Report confirmed R1 is incontinent but able to communicate needs. Lastly, All other residents interviewed confirmed they receive proper incontinence care and are changed as needed. Therefore, based on interviews, observations, and record review, there is insufficient evidence to support the allegation. Therefore, the allegation that staff did not ensure R1 was kept clean is deemed Unsubstantiated at this time.
Continue on LIC 9099C
Staff did not provide shower assistance to resident in care.
It was reported that Resident 1 (R1) had not been receiving regular showers and subsequently developed cradle cap on their scalp. To investigate this allegation, LPA conducted interviews and observations. Interview with WD denied the allegation and stated that all residents, including R1, are provided with shower assistance at least two (2) times a week or as needed. Moreover, during the initial visit, R1 informed LPA that they are receiving assistance with showers and expressed no concerns. R1 was observed to be clean, well-groomed, and free of odor. Lastly, nine (9) out of nine (9) residents interviewed stated they receive proper care, including showers, and voiced no concerns related to the allegation.
Based on interviews and observations, there is insufficient evidence to support the allegation. Therefore, the allegation that staff did not provide shower assistance to R1 is deemed
Unsubstantiated
at this time.
Resident's room was not kept clean by facility staff.
It was alleged that urine was present at the bottom of the toilet and that the resident’s room was unsanitary. It was further alleged that food debris and crumbs were observed underneath the bed.To investigate these allegations, On 09/10/2025, LPA conducted interview with WD and on 09/30/25 with Executive Director (ED), and
Maintenance Director (MD)
. All parties interviewed denied the allegations and stated that the facility conducts daily tidy-ups lasting approximately fifteen (15) minutes and weekly deep cleanings lasting approximately forty (40) minutes for all residents’ rooms. Furthermore, LPA was informed that R1’s room received additional cleaning services due to R1’s roommate exhibiting poor hygiene and at the request of R1’s family. These additional services were provided at no extra cost to R1.
Moreover, LPA reviewed the facility’s housekeeping schedule and observed that the facility employs three (3) housekeepers responsible for performing weekly deep cleaning of fifty (50) resident rooms. During the initial visit, LPA conducted a physical plant tour and observed that all rooms, including R1’s room and bathroom, were clean and free of food debris and crumbs. Lastly, interviews conducted with nine (9) out of nine (9) residents revealed no concerns regarding room cleanliness. All residents interviewed confirmed that their rooms are cleaned daily or as needed.
Based on the information obtained during the investigation, including staff and resident interviews and a review of facility records, there is insufficient evidence to support the allegation that the facility failed to maintain a clean and sanitary environment. Therefore, the allegation is deemed
unsubstantiated
at this time.
Exit interview conducted and copy this report signed and delivered.
Staff did not prevent residents from engaging in inappropriate interactions.
It was reported that two residents were engaging in inappropriate interactions with each other in the lunch area of the facility. To investigate this allegation, LPA conducted an interview with the Wellness Director (WD), who admitted that on 01/01/2025, between approximately 2:00 PM and 3:00 PM, two (2) residents were observed engaging in an inappropriate interaction in the lunch area in the presence of other residents and visitors. The receptionist was notified by a witness and intervened to separate the residents. However, the receptionist did not move the residents far enough apart, resulting in the residents engaging in another inappropriate interaction shortly thereafter.
On 09/29/2025, LPA conducted telephonic interviews with the Executive Director (ED) and the receptionist. Both confirmed the information provided by WD and reported that no staff were assigned to provide care and supervision in the lunch area between 2:00 PM and 3:00 PM, as that time was outside of regular meal service hours. Based on information obtained through interviews, there was insufficient staff supervision at the time of the incident, which resulted in residents engaging in inappropriate interactions. Therefore, this allegation is Substantiated.
Deficiency issued and appeal rights explained.
Exit interview conducted and copy of this report signed and delivered.
