Complaint Investigation Report

Regarding the allegation Staff are not following reporting requirements. LPA Hurt reviewed Madonna Gardens facility online file, and there are no reports from the facility for 12/2023. LPA Hurt reviewed facility care notes for Resident 1 , documenting Resident 1 fell and was transported to the local hospital. This incident was not reported to State Licensing. Based on records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff undressed residents in the common area in front of visitors. LPA Hurt interviewed two facility staff who both stated on 05/18/24 facility Staff 1 requested female Resident 2 to lift the back of her shirt up past her undergarments to conduct a skin check in front of other facility residents, and visitors. Facility staff did not provide skin check sheets from 05/18/24 for review. Based on LPA interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cited Per Title 22 Regulations, and a copy of this report provided.

Exit interview conducted with facility Administrator Renee Hamilton, and copy of report provided.