Complaint Investigation Report

Regarding the allegation “Facility staff did not provide resident medication as prescribed”: LPA reviewed medication records; it appeared medications were given to R1 as prescribed. The complaint alleged PRN medications were not given. LPA observed PRN medication was given as requested by hospice nurses. Staff stated on or about 5/15/2025, R1 was unable to self administer medications due to being so sedated from prior doses. The hospice nurse wanted R1 to receive another dose of a sedating medication but R1 was already too sedated and could not self administer. The hospice nurse somehow administered the new medication order. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Facility staff handles residents in a rough manner”: LPAs interviewed staff and witnesses regarding this allegation. There were no witnesses to any residents being handled in a rough manner. Based on interviews this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegations “Facility staff do not ensure resident's hygiene needs are being met” and “Facility staff are not assisting with soiled diapering in a timely manner:” LPAs interviewed staff and witnesses regarding these allegations. Bathing is provided on a schedule or more often as needed. Residents on hospice are bathed by hospice personnel on a schedule and hygiene is provided as needed by facility staff. Residents’ incontinence care needs are checked every one to two hours or more often as needed. Witnesses who were interviewed stated they did not have any concerns about hygiene and incontinence care provided by the facility staff. Based on interviews these allegations are deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Facility staff are not communicating with the residents’ hospice agency representative”: LPA’s interviewed staff and witnesses and reviewed documents. Based on documentation received by CCL, whenever there is a reportable incident involving residents at the facility who are on hospice, the hospice agency is also notified. Based on interviews with staff and witnesses, the facility communicates with hospice and family members when a resident on hospice has any issues that must be addressed. Based on interviews and records reviewed, this allegation is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted and report issued.