complaint·March 20, 2025

Regarding the complaint allegation: Staff did not follow the medication orders as prescribed. During the investigation it was discovered R2 was being seen by a Home Health Nurse who was treating the irritated areas to R2’s tailbone and private area with barrier cream and off-loading. According to Staff 1 (S1) rotating the resident was important. Staff was advised to rotate the resident at least every two hours. Home Health came to treat the affected area once a week. However, the Home Health Nurse was in the facility daily and would see R2 upon request if needed, according to S1. Based on the information gathered through interviews and document review, the following allegations: Facility did not prevent resident from eloping, and Staff did not follow the medication orders as prescribed are deemed unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.