complaint·July 17, 2025

order for facility staff to complete and assist with the resident's care needs. It was learned that R1 was able to ambulate and move about the facility independently but often times refused to do so. R1 did have the use of a wheelchair and walker at this time. It was learned that R1 did have a tendency to throw themself on the floor even though R1 was able to get up and move themself off of the floor. By doing this, R1 did suffer lacerations and bruises from self harm and did so even in the presence of the facility caregivers. It was learned that it was very difficult to re-direct and de-escalate behavioral outbursts when R1 got angry. It was learned that the behaviorist recommended that facility staff not engage with R1 when R1 was triggered with their behaviors so that it would slowly calm the situation down by not affirming R1's attention seeking behavior. It was learned that R2 moved into this facility in the latter part of 2024 but this facility was instructed by R2's attending physician that R2 be placed on a lactose free diet due to health concerns. It was observed that the facility menu did take this into account and the meals that were prepared for this resident reflected this detail even though it was not required that this facility maintained and followed a set menu at all times. It was learned that milk was always offered for all meals if desired by the other facility residents. Based on a review of the forms and documents retrieved during the course of this investigation, it was learned that R3 had an in-dwelling catheter, upon admission, which required care in cleaning and maintaining. A review of the medical records for R3 revealed that there was an incident where it was discovered that R3 had sustained a Urinary Tract Infection (UTI) on 01/30/2025. Medical records were reviewed for R3 detailing admission into the local medical institution for treatment and eventual discharge with antibiotics at that time. It was observed that the prior hospital visit conducted for R3 in December 2024 did not present any issues related with the catheter. It was observed that it was noted as being present at that time without any further issues. It was observed that a care plan was put into place where R3 would receive regular maintenance with R3's catheter and have it removed, cleaned, and re-inserted at the local medical institution on a monthly basis. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview