On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R1’s file and found no records to verify whether R1 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R1 therefore, LPA was unable to verify if their medications were given or not.

LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.

#3- Allegation: Staff did not provide daily activities for residents.

On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1 – S10), of those interviewed, 10 out of 10 stated residents are provided with daily activities and showed a schedule of activities on the wall posted and provided a printed copy.

LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they have engaged in daily activities the remaining 6 residents were unable to engage in a clear conversation.

On May 12, 2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review.

Continued

#1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff.

On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1–Staff 10 (S1–S10). Of those interviewed, 10 out of 10 staff denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care.

LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated that they do not have any pressure injuries and based on LPA observations there was no visible pressure injuries. The remaining 6 residents were unable to engage in a clear conversation and LPA did not observe any visible pressure injuries.

LPA reviewed R1’s facility file and found no medical records indicating wound care services were provided. The needs and service plan dated 4/28/2023–10/16/2023 does not indicate the presence of a pressure injury. However, hospice records from Specialty Hospice confirm services were provided 2x/week from 06/14/2024–10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024–10/11/2024. LPA could not obtain sufficient evidence to substantiate that R1 sustained a pressure injury due to a lack of care by facility staff.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.

On May 12, 2025, the LPA conducted interviews with Staff 1 - Staff 10 (S1– S10), of those interviewed, 10 out of 10 state all residents in care receive three meals daily, including snacks and meals are determined based on their dietary needs. S10 stated that R1 was on a fortified mechanical soft meal and thin liquids but specific dates could not be provided. LPA reviewed R1’s physicians report date 4/27/2023 and Specialty Hospice Care dated 6/14/2024 which states R1 was on a fortified mechanical soft meal and thin liquids.

Additionally, LPA interviewed Residents 2 - Resident 8 (R2–R8); 2 stated they receive three meals daily, the remaining 6 residents were unable to engage in a clear conversation.

On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice.

On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus which coincides with the meals being provided for each day. A tour of the facility kitchen was also conducted, during which LPA observed a five-day supply of perishable food and a seven- day supply of nonperishable food items were noted. The kitchen appeared clean, and no health or safety concerns were observed during the visit.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated.

An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.