Complaint Investigation Report

Allegation: Facility staff do not maintain documentation of resident(s) records.

It is alleged that facility staff do not maintain documentation of resident records. Regarding this allegation it is reported that Administrator retained and admitted residents into the facility without proper documentation. LPAs interviewed Administrator who admitted to accepting Resident #1 (R1) on 05/26/25, however Administrator stated that they were within the seven (7) days allotted to obtain a signed and finalized Admission Agreement. LPAs inquired on the rest of the documents required for each resident file and Administrator stated that they were not able to complete a file for R1 as R1 was admitted to the hospital the following day on 05/27/25. Administrator admitted to not having a medical assessment for R1 prior to admitting R1 as a resident in the facility. LPAs reviewed resident files and discovered that all documents that are required were in three (3) out of three (3) current resident files. Interviews with Staff #1 (S1) revealed that they are not involved in anything pertaining to documents, they simply care for the residents. Therefore, based on file reviews and interviews, this allegation is deemed substantiated.

Citation issued. Appeal rights discussed and provided. Exit interview conducted and a copy of report given to Administrator.