Complaint Investigation Report

Regarding the allegation Staff do not meet the needs of residents diagnosed with a restricted health condition: Based on interviews and records reviews, R2 does not have a Home Health Care Plan. Based on interviews Staff are draining catheter bag without training from Home Health. Staff are cleaning the insertion area of the catheter. Facility does not have a restricted health care plan for R8's restricted health condition or staff training.

Regarding the allegation Staff do not provide adequate care and supervision of the residents: Based on records review and interview, facility staff did not respond to change feces soiled brief for R1 for several hours. After conducting staff interviews facility staff stated response time to call lights is 5 minutes. After review of records of call light system for June 18, 2025 to June 25, 2025 several were over 15 minutes to 1 hour and 45 minutes.

Regarding the allegation Staff are not following proper reporting requirements. Resident 1, and resident 4 were not given prescribed medication for multiple days during the month of June 2025. Facility staff did not report the missed medication to Licensing as required.

Regarding the allegation Staff are mishandling the residents medications. Resident 1 and Resident 4 missed multiple prescribed medications during the month of June 2025. No reason was documented as to why medications were not being administered to residents. R4 should have had a medication administered at 8 PM and did not get the medication until 10:19 PM.

Based on records reviewed interviews and observation for the allegations preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A copy of this report with plans of correction and appeal rights were provided.