complaint·March 11, 2026

It was further alleged that facility staff did not follow physician's orders by not insuring resident used Compression Socks Interviews with staff report that they put R1’s compression socks on in the morning, and removed them at night, care staff washed the socks so they would be clean for the morning. This is consistent with resident’s care plan. This allegation is Unsubstantiated It was alleged that facility staff did not follow resident's care plan. Specifically that R1 was in the bathroom and a care giver was further away from the bathroom that they should have been. Interviews and a review of the resident’s care plan states that staff will “Provide as much privacy as possible during bathing” for R1. This allegation is Unsubstantiated. It was further alleged that the facility did not centrally store resident's medication. Specifically that R1’s prescription shampoo and another unidentified medication were in R1’s room. Interviews revealed that medication is taken directly to the med room upon arrival from the pharmacy. Prior to R1’s bathing, facility staff get the prescription shampoo from the medication room and when the care has been provided return it to the medication room. No information was revealed that any other medication was in R1’s room when it should have been centrally stored. This allegation is Unsubstantiated. It was further alleged that facility staff did not ensure R1 was hydrated as evidenced by R1 being hospitalized for dehydration Interview revealed numerous ways staff are trained to encourage liquid consumption by residents and to monitor for signs of dehydration. A review of the “after visit summary” from the period of hospitalization that was specific to this allegation does not mention dehydration as a cause of the hospitalization, R1 was discharged with new medication and referral to a hospice agency. This allegation is Unsubstantiated. Lastly it was alleged that resident’s documents were inaccurate. Specifically that S2 logged that they had come in to assist R1 when S2 did not. Interviews determined that there were logs in R1’s room that were placed there by an outside source. Any such logs or other documents are not facility documentation. No evidence was revealed that the facility’s documentation was not completed accurately. This allegation is Unsubstantiated. Based on interviews and a review of documentation above allegations are UNSUBSTANTIATED meaning that the evidence did not meet the preponderance of evidence standard and is insufficient to compel further action. An exit interview was conducted with Risa Jester; a copy of this report and Licensee's Rights (LIC9058) were provided.