complaint·June 5, 2025

R1's friends/family visit R1 at the facility approximately three (3) times per week and no one has reported observations of R1 being restrained in the facility. Friend/family visits are unannounced and R1 is always observed well kept with no foul odors, eating well, and with clean bedding. R1's responsible person did not express any issues or concerns with the care and supervision R1 receives in the facility. LPA reviewed a prescription order for R1 dated 1/21/2025 stating R1 "needs a soft blanket tied in front for postural support and safety". Lukic was interviewed and reported the soft blanket tied in the front is occasionally placed on R1 for better support and to prevent them from falling. Lukic added R1 has the ability to untie the soft blanket on their own and staff was trained on how to properly tie the soft blanket. One (1) staff was interviewed and corroborated the information provided by Lukic. Regarding the allegation, "Facility is exceeding hospice waiver capacity" it was alleged the facility is licensed to house two (2) hospice residents and currently has four (4) residents on hospice. LPA conducted a record review which noted on 3/1/2024, the facility was granted a hospice waiver increase for a total of three (3) residents. Lukic was interviewed and reported Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), and Resident 5 (R5) are currently receiving hospice services at the facility. A review of admission agreements and hospice care plans note R2, R3, and R4 were admitted to the facility sometime in 2023 or 2024 and all three (3) residents were admitted to hospice in 2024. A review of R5's admission agreement and hospice care plan indicates R5 was admitted to the facility on 5/3/2021 and to hospice on 5/23/2025. On 5/22/2025, LPA received an email from Licensee, Snezana Lukic with a hospice waiver increase request to house four (4) terminally ill residents at a time. Lukic reported the facility has not accepted any new residents who were on hospice upon admission to the facility and licensee submitted an hospice waiver increase request as soon as they learned R5 would be admitted to hospice. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided to Lukic along with a Confidential Names list (LIC 811).