complaint·December 29, 2025

Allegation: Staff are mismanaging residents' medication-Substantiated On 05/01/2025 LPA Ratajczak and LPM Munoz conducted a medication audit for five (5) residents. During the medication audit, the following was found: Resident #5 (R5) Discontinued order for Baclofen on 04/25/25. LPM and LPA observed medication to still be in the medication cart. Resident #6 (R6) Discontinued order for Aspirin on 04/29/25; for Breztru inhaler on 04/29/25 and for PreserVision AREDS on 04/15/2025. It was observed that all discontinued medications were in the medication cart. R6 had an order for Norco on 03/16/2025, the medication was not ordered and not in facility . Resident #7 (R7) Discontinued order for Midodrine on 04/24/25. LPM and LPA observed medication to still be in the medication cart. Based on information obtained, the allegation is found 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. Exit interview conducted a copy of the report provided and appeal rights provided. Allegation: Staff do not ensure residents' showering needs are being met- Unfounded Interviews revealed that residents receive their showers as scheduled. Sometimes showers are moved around but the shower is usually pushed back to the next shift. If a resident is not feeling well, they will ask staff to come back at a later time or to be moved to another day. Resident interviews revealed that some have hospice come in and give them showers also. Allegation: Staff do not ensure residents’ incontinence needs are being met-Unfounded Interviews revealed that staff check on residents every one to two hours for incontinence care needs. Depending on residents care needs, they may be checked more than every two hours. Residents will also push their pendants if they need any assistances between checks and staff respond. Allegation: Staff are not repositioning resident as needed- Unfounded The department conducted interviews with residents and staff regarding this allegation. Interviews with staff revealed that they reposition residents every two hours unless care plans specify otherwise. Resident interviews revealed that they have staff that come in and reposition them throughout the day. Allegation: Staff did not prevent resident from developing a pressure injury-Unfounded Interviews with residents revealed they currently do not have any pressure injuries or if they do they are being treated by hospice. Staff interviews revealed that those who do have a pressure injury they are already being treated by hospice. Allegation: Staff do not ensure residents' hygiene needs are being met-Unfounded Interviews with staff revealed that a resident’s care needs are documented on their care plan. Staff assist resident’s with hygiene needs based on a resident’s care plan and the resident’s preference. Allegation: Staff do not ensure that resident has clean bedding- Unfounded Interviews revealed that housekeeping will clean the bedding on the day the resident’s room is cleaned. In between that time care staff will observe to see if the sheets need to be changed in-between. If bedding needs to be changed, caregivers will change the bedding. Allegation: Staff do ensure resident rooms are clean and sanitary-Unfounded Housekeeping cleans the resident’s rooms once a week. In between that time if some additional cleaning is needed caregivers will assist. LPA observed nine (9) residents bedrooms. All rooms were observed to be clean and sanitary. Some residents do have animals. Those animals are the residents responsibility and to clean up after them if they are to go in their rooms. Residents who can no longer care for their animals families will hire outside help to come in and care for the animal. Interviews revealed that staff will clean up the animal feces if they see it when they are in the rooms. Based on information obtained through interviews, the Department finds the allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.