complaint·June 3, 2025

Continued from LIC9099 Complainant looked through box and could not locate any of R1’s alleged missing items. Interview with witnesss (W1 & W2) indicated they were unaware of any missing items or that R1 wore glasses. LPA conducted facility visit on 3/27/2025 and observed R1 to have adequate hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not safeguard resident’s personal belongings is Unsubstantiated . Staff did not bathe a resident in care - Complainant alleges resident went ten days without having a shower. Follow up interview with complainant informed it was after R1 returned from the hospital in either January 2025 or February 2025 when staff informed it has been 10 days since R1 had a shower due to R1’s refusal to take a shower. Resident progress notes indicated R1 returned from the hospital on 1/23/2025 and had a shower that day. Shower log for R1 indicates they have showers on Sunday’s and Friday AM’s and had one on 1/23/2025 after returning from the hospital, the following shower was given on Sunday 1/26/2025 as scheduled. Refused on 1/31/25 but given on February 2, 2025. Interview with S2 revealed they would mention to the family/POA that there were days where R1 would refuse baths/showers, there was never a time they indicated there had been 10 days since a shower had been given. LPA was informed, if a shower cannot or resident refuses to have a shower on designated shower day’s staff will attempt the follow day and night. LPA conducted interviews, record reviews, and made observations of R1 having satisfactory hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff did not bathe a resident in care is Unsubstantiated . Staff obtained care giving services for a resident without consent from resident's responsible party - Complainant alleges after R1 returned to the facility from the hospital on 1/23/2025. The following week the complainant informed they received a phone call that R1 pushed a resident, at which point the facility requested for R1 to be put back on a medication that was recently d/c’d and/or 1:1 staff to be implemented. CCL received SOC341 (2/18/25) (smacked R2 in the chest (female resident) on (2/19/25) hit R2 again, this time on left arm. On 2/14/25 2 nd SOC341 R1 pushed R3 (female resident against the med tech office door) Resident agreement references pg 10 paragraph F regarding One on one care “ If it is determined by the Community staff that you are a danger to yourself or others, you may be required to receive one-on-one care and supervision for an additional charge as set forth in Appendix A, or for the cost of all services provided by Outside Provider and billed directly to you. Continue on LIC9099-C2 Continued from LIC9099C1 Interview with Administer informed family was advised by Nurse of the possible 1:1 being needed. LPA obtained email correspondence with RP and facility, dated 2/21/2025, email states that R1 due to behaviors requires a 1:1 caregiver. Care conference was held on 2/20/2025. R1 moved out of the facility 4/11/2025. Based on interviews conducted and record review, the facility communicated R1’s care needs with RP prior to implanting. Therefore, the allegation Staff obtained care giving services for a resident without consent from resident’s responsible party is UNSUBSTANTIATED . A finding of Unsubstantiated means, 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 . No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents Continued from LIC9099-A This agency has investigated the complaint alleging staff did not allow resident’s responsible party to use a medical pharmacy of their choice. We have found that the complaint allegation was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Business Office Director. Signature on form confirms receipt of documents