Complaint·July 18, 2025

It was alleged staff refused to allow resident the ability to collect their personal belongings after eviction. Information received indicated that Resident #7 (R7) came to the facility to get their belongings, but the management did not allow R7 to do so. LPA’s records review revealed R7 was lawfully evicted on 10-24-2024. LPA verified the eviction via court documents provided for review. Per the court document, the landlord is responsible for the safe keeping of tenant’s property for fifteen (15) days from the date of eviction. Per the Administrator, R7 never came back to the facility to claim their personal property. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided. It was alleged staff chemically restrained resident(s) in care. Information received indicated that staff intentionally administered extra medication to keep residents sedated. LPA’s file reviews revealed both Resident #1 (R1) and Resident #4 (R4) had been on hospice care plan. Both R1 and R4 passed away. LPA conducted interviews with five (5) staff members and seven (7) residents, all of whom denied witnessing or being aware of chemically restraining a resident. Both the Administrator and medication technician stated medication dispense is strictly followed by residents’ physician’s orders. LPA’s review of medication records for both R1 and R4 did not find any corroborating evidence of over medication or medication errors. This allegation is unsubstantiated . It was alleged Licensee retained a resident with a higher level of care needed. Information received indicated that staff retained a resident who should have been placed in a memory care facility. LPA’s review of records revealed Resident #6 (R6) was non-ambulatory who had been under hospice care. LPA’s review of resident file revealed R6 did not have dementia diagnosis or wandering behavior. LPA’s review of physician’s report and facility’s assessment did not find any corroborating evidence that R6 required higher level of care. This allegation is unsubstantiated . It was alleged staff did not follow physician’s instructions regarding resident’s diet. Information received indicated that Resident #3 (R3)’s food was to be pureed. LPA’s review of records revealed R3 is currently at a hospital and required special diet per the resident’s physician’s order. The physician’s order stated R3’s meal must be mechanical sort chopped with thin liquids. Administrator and wellness director stated the kitchen staff always provide any special diet in the resident’s care plan and physician’s order. LPA’s interview with kitchen staff corroborated the statement from the Administrator and wellness director. This allegation is unsubstantiated . It was alleged staff did not ensure resident(s) were sufficiently fed. Information received indicated that staff did not bring food to Resident #4 (R4). LPA’s records review revealed R4 was non-ambulatory and required a Hoyer lift for transfers. R4 passed away in April 2025, while receiving hospice care. The Administrator stated R4 was receiving tray service where meals were delivered directly to the resident’s room, at no additional cost. This accommodation was made due to R4’s limited mobility and care needs. The Administrator stated R4 consistently received meals in accordance with their admission agreement and dietary requirements. Tray service was provided three times daily, and staff were instructed to ensure meals were delivered and consumed as appropriate. Continued on LIC9099-C.... LPA interviewed five (5) staff members. All staff members affirmed that residents are provided with three meals per day, and that additional snacks or special dietary accommodations are made based on individual needs. LPA interviewed seven (7) residents currently residing at the facility. All residents confirmed they receive three meals daily and denied any instances of missed or insufficient meals. Based on the review of records, staff and resident interviews, there is no evidence to support the allegation that residents were not sufficiently fed. All findings indicate that residents receive regular meals in accordance with their care plans and admission agreement. Therefore, this allegation is unsubstantiated . It was alleged staff did not ensure that resident’s catheter was maintained. LPA’s review of records revealed Resident #3 (R3) is currently at a hospital due to conditions unrelated to the catheter. R3 is under hospice care plan and requires use of catheter. LPA conducted an interview with the Administrator. The Administrator explained that facility staff are limited in the scope of catheter care they can provide. Specifically, staff are permitted to drain the catheter bag and clean the surrounding area, but full catheter maintenance, including insertion, replacement, and clinical assessment, is the responsibility of hospice care personnel. The Wellness Director confirmed the Administrator’s statement, emphasizing that catheter maintenance falls under the duties of licensed hospice staff, not facility caregivers. LPA interviewed five (5) staff members. All staff reported that incontinence care, including draining catheter bags, is performed every two hours or as needed, depending on the resident’s condition. LPA interviewed seven (7) residents. All residents stated they receive appropriate and timely incontinence care. Based on the review of records, staff and resident interviews, and clarification of care responsibilities, there is no evidence to support the allegation that the resident’s catheter was not properly maintained. According to record reviews and interviews conducted, catheter care was routinely managed by hospice personnel, and facility staff perform their assigned duties within scope. Therefore, this allegation is unsubstantiated . It was alleged staff handled resident(s) in a rough manner. Information received indicated that staff would handle residents in a very rough manner. LPA interviewed five (5) staff members. All staff members denied having witnessed or engaged in any rough handling of residents. They reported that care practices are conducted in accordance with facility rules, emphasizing safety, dignity, and respect. LPA interviewed seven (7) residents currently residing at the facility. All residents denied experiencing or observing any rough handling by staff. Each resident stated that staff consistently provide care in a respectful and gentle manner. During the investigation, LPA observed staff interactions with residents during routine care and facility activities. Continued on LIC9099-C.... Staff were seen assisting residents with attentiveness and professionalism, using appropriate techniques for mobility and personal care. Based on consistent statements from both staff and residents, as well as LPA’s direct observations, there is no evidence to support the allegation that residents were handled in a rough manner. Therefore, this allegation is unsubstantiated . It was alleged staff left resident in soiled bedding. Information received indicated that staff do not change catheter for Resident #3 (R3), and it will overflow. LPA’s records review revealed R3 is currently at a hospital. LPA’s interviews with five (5) staff members revealed incontinence care and bedding changes are provided every two (2) hours or as requested, depending on the residents’ needs. Three (3) of the seven (7) residents interviewed stated they required incontinence care and stated the staff have provided incontinence care and bedding change promptly. Based on the absence of corroborating evidence and consistent statements from both staff and residents confirming appropriate care practices, this allegation is unsubstantiated . It was alleged staff did not assist with toileting as required. Information received indicated that staff would not provide incontinence care for Resident #8 (R8). A record review conducted by LPA revealed Resident #8 (R8) passed away in April 2025 while receiving hospice care. Interviews conducted by LPA with five (5) staff members indicated that incontinence care is provided every two hours or upon request, based on the individual needs of residents. Of the seven (7) residents interviewed, three (3) reported requiring incontinence care and affirmed that staff have provided such care in a timely manner. This allegation is unsubstantiated . A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.