Complaint·September 15, 2025

Review of R1’s medical assessment records dated May 8, 2025, revealed that R1 required assistance with All Activities of Daily Living (ADLs) except for feeding themself and were non-ambulatory. Also, according to R1’s medical assessment they required a modified diet of mechanical soft and no added salt. Review of R1’s medications list revealed that R1’s diuretic medication was discontinued by a physician. Also, internal and external interviews did not reveal that R1 was not receiving their rash ointment as prescribed. Review of R1’s care plan dated May 18, 2025, revealed that R1 required frequent safety checks and these checks would occur every two hours or as needed and R1 required escorts to and from the dining room. Interviews corroborated that R1 did receive safety checks and was escorted to and from the dining room. Interviews did not reveal that R1 received fried foods, nor did it reveal that R1’s modified diet was not followed. Due to R1’s baseline memory loss they were unable to be used as a reliable historian to aid in this investigation. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that that staff did not administer medication as prescribed, staff did not follow resident’s care plan, and staff did not follow resident’s modified diet. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director Danenhauer, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.