complaint·May 12, 2025

Staff cut resident’s hair without consent from authorized representative. – Substantiated Staff cut R1’s hair without obtaining prior consent from the authorized representative, which is a violation of the R1’s personal rights. However, there is no evidence that the resident sustained any physical or emotional harm. Based on staff and resident interviews the investigation revealed that the facility provides routine haircuts to male residents every three to five weeks as part of grooming and hygiene care. According to the Executive Director (ED), Resident 1 (R1) typically does not request a haircut, and in this case, a caregiver independently decided to cut R1’s hair, citing hygiene concerns due to the residents at the time. The caregiver did not obtain prior consent from R1’s authorized representative. Although the facility stated that routine haircuts are standard practice, staff failed to obtain consent from R1’s authorized representative prior to the haircut, which is required. There was no indication that R1 experienced emotional distress, physical injury, or any other form of harm as a result of the haircut. As a result of this investigation, LPA finds allegations to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Staff does not ensure call button is accessible to resident. – Unsubstantiated During staff interviews, staff reported each client has a pull cord at bedside and in each bathroom. Based on investigation, LPA Gunby observed each resident room has a pull cord on the wall by resident bed and one in each resident bathroom. LPA Gunby observed a R1’s room with a pull cord attached to the wall with a longer cord for easier access to pull. LPA Gunby requested call button logs and observed only several residents using the call buttons. Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Staff not keeping an accurate medication log. – Unsubstantiated During the initial visit and walk through, the medications were reviewed, and it was noted that the facility staff were logging all new and current incoming medications and prescriptions. It was also observed in the medications log that the staff were checking off that they are giving the resident their medication. The ED stated that if they were to dispose of medication for a resident, that there would be two staff persons that would witness the disposal and that the two staff persons would sign and log that they did dispose of the medication. Based on the investigation, observations and interviews conducted the allegation is UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.