Complaint·August 13, 2025

According to medical records, resident (R1) was sent out to the hospital on October 8, 2024, October 29, 2024, and November 23, 2024. Upon review of medical records, there was no indication that the facility did not seek timely medical attention for R1. Interviews with S2, home health nurse, administrator, and licensee indicated that, when R1 fell out of their bed on October 8, 2025, they were sent to the hospital. Home health records indicated that R1 was sent to the Emergency Room on October 8, 2024. Interview with S1 indicated that staff seek timely medical attention for residents by contacting emergency medical services or hospice services. Interviews with the home health nurse and administrator indicated that R1 was having constipation issues due to pain medication. Home health nurse indicated that R1 was receiving suppositories for constipation that were not working. Home health nurse and administrator indicated that R1 was sent to the hospital and prescribed a stool softener due to suppositories not working. Home health nurse and administrator indicated that a bowel movement (BM) chart was kept for R1. Facility provided R1’s BM chart for November 2024, which did not indicate any missed BM. On January 24, 2025, LPA conducted a medication count for residents (R4, R5, and R6), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. Interviews with R2 and R3 indicated that they receive all their medications as prescribed. Interviews with S1, S2, S3, and S4 indicated that all residents are receiving their medications as prescribed. Interview with the home health nurse indicated that they had no concern regarding the facility providing medications to residents as ordered. Interviews with S1, S2, S3, and S4 indicated that they have never witnessed staff handling residents in a rough manner. Interviews with R2 and R3 indicated that staff have never handled them too roughly and they have never witnessed staff handling other residents in a rough manner. Based on medication count, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.