complaint·July 8, 2025

The investigation revealed the following: Allegation: Staff are inappropriately restraining a client in care. It is alleged that the facility is using an unauthorized physical restraint on R1 that ties R1 to their bed. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that they have never used restraints on any of their residents. LPA interviewed 3 residents and 2 out of 3 residents denied the above allegation. R1 stated there was a time that staff would worry over R1 getting out of bed in the middle of the night as the risk of fall was there but they have never been restrained to their bed nor have they observed other residents being restrained in any way. LPA interviewed R2 and it was stated that they believe that R1 at one time was restrained to their bed but could not confirm as they never physically saw the restraint. Interviews with 3 other residents were not conducted due to cognitive impairments. LPA toured R1’s bedroom and looked under mattress around bed and under bed, there were no signs of restraints being any where in room or near R1’s bed. (unsubstantiated) Allegation: Staff are not administering resident's medications as prescribed. It is alleged that the facility staff are using excessive medication on R1. LPA interviewed 4 staff and 4 out of 4 staff denied the above regulation and stated that all medications, supplements and vitamins have a prescription and are administered per the doctors orders. LPA interviewed 3 residents and 3 out of 3 residents denied the above allegation and stated they feel the staff are giving their medication as prescribed and all medication looks the same with no changes noticed or concerns. Interviews with 3 other residents were not conducted due to cognitive impairments. LPA reviewed medication and the Medication Administration Record (MAR) and observed the following: MAR was not being documented properly as June 29-30, 2025 and July 1, 2025 were not signed for by the staff that assisted with administering medications each of those days, LPA spoke with S2 and S2 stated they did give the medications per doctors orders, however, they forgot to sign the MAR. LPA o bserved R1’s medication list provided by their doctor, there were PRN medications listed (as needed medication), however, those medications were not in R1’s Medication basket, when LPA questioned S2 about this medication they stated they have not refilled the medication for R1. (unsubstantiated) Although LPA did not find proof of R1 being over medicated, a citation will be issued today (7/8/25) for the missing PRN medication in a separate report via Case Management visit. (Continued on LIC9099-C) Allegation: Staff did not prevent client from losing excessive weight. It is alleged that since R1’s admission in December 2024, R1 has presented with documented weight loss. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that since admission R1 has gained a healthy amount of weight as their condition and appetite has improved. LPA interviewed 3 residents and 3 out of 3 residents denied the above allegation, R1 stated they have noticed a bit of weight gain within themself as they enjoy the food at the facility and their appetite has improved. LPA reviewed R1’s Physician Report dated 10/21/24 and additional medical record dated 1/10/25 both had the same weight, during initial visit 7/1/25 staff weighed R1 and LPA compared it to the weight records and it showed a weight gain of 8 pounds. (unsubstantiated) Based on statements and interviews conducted with staff/residents, review of R1's files and Medication Review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview held, and a copy of this report was provided.