Complaint·May 15, 2025

Staff did not ensure resident's incontinence care needs were properly met In review of records and interviews, care staff were ensuring that resident (R1) was being checked on or being changed every two (2) hours R1’s needs and service plan. According to R1’s assessment completed on December 12, 2024, staff were responsible to “assist with toileting according to schedule, need and requests”. Based on records reviewed and interviews, care staff ensured that R1’s incontinence care needs were appropriately met. Facility has insufficient staff to meet the care needs of residents in care - Interviews indicate that there is sufficient staffing to meet the care needs of the residents. Staff are able to address resident needs in an efficient and timely manner. Observations indicate that staff are available to ensure that residents needs are being addressed either by seeing a need or the call button system. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Staff did not follow resident's physician orders Interviews with Executive Director (ED) and Health Services Director (HSD) indicated that the staff were following correct procedures for Resident (R1) care needs according the R1’s care needs assessment. Review of R1’s records indicated that R1 was receiving a re-assessment by HSD every six (6) months to ensure accuracy of R1’s care needs. In records reviewed, care staff and med-techs were following physician’s orders that were sent to facility. Staff mismanaged resident's medications Review of facility’s medication room indicated that medications were organized and free of clutter. In review of Medication Administration Record (MAR) for three (3) residents, medications are being dispensed and given according to physician’s orders on file. In review of Centrally Stored Medication Record (CSMR) for three (3) residents, all medications were documents according to physician’s orders on file. Med- techs document each time a resident takes a medication, refused or not given for a specific reason through the Electronic Medication Chart. Staff did not issue refund to resident's authorized representative Interview with Executive Director (ED) indicated that a refund was sent although Resident (R1)’s responsible party did not provide a thirty (30) day notice to facility per the admission agreement signed by R1’s Power of Attorney (POA). R1’s responsible party did not provide anything in writing, only verbally, to facility stating R1 was moving out of the facility on 03/17/2025. Interviews indicated that R1’s responsible party came to facility on 03/17/2025 and started packing R1’s belongings to move R1 from facility with no notice to staff or the ED. In review of Resident R1’s admission agreement, agreement states that “if you move out without a thirty (30) day notice, you will be responsible for the amount of your monthly fee through the date you move plus one full month’s rent”. The admission agreement was signed by R1’s power of attorney acknowledging the terms and agreements prior to moving in the facility. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.