R1’s Physician Report dated 09/12/2024, stated R1 was unable to bathe or groom themselves and was non-ambulatory. Review of R1’s wellness physician order dated 09/13/2024 stated that R1 was not to participate in facility’s fitness program. Order did not provide additional information on mobility aids.

Review of Facility documents showed multiple updates to R1’s plan of care:

· R1’s care plan dated 09/20/2024 stated that R1 needed caregiver assistance with bathing; they could dress and undress and select their own clothing but may need reminders/supervision and was independent with grooming and personal hygiene care. This care plan stated that they required mobility escorts with a walker as a mobility aid.

· On 09/29/2024, R1’s care log noted that a phone call conference was held with R1’s responsible party. On 09/30/2024, R1’s care plan was updated to the following - R1 did not require assistance with the following tasks: bathing, dressing, and grooming. This care plan stated that they required mobility escorts with a walker as a mobility aid.

· On 12/04/2024, R1’s care plan was updated again to show that R1 required help with the following tasks: assistance with bathing set-up, one person assist with dressing and grooming as scheduled. This care plan stated they required mobility escorts with a walker or wheelchair as a mobility aid.

· On 12/17/2024, R1 was admitted to a hospice agency and received an updated care plan. Review of R1’s hospice care plan stated “activities permitted: up as tolerated. Transfer bed/chair; wheelchair, walker.”

Email correspondence provided indicated that the facility was aware of concerns with R1’s care. Email dated 09/15/2024, stated that flexibility would be needed on the timing of R1’s care because facility staff wouldn’t always be able to see R1 at a designated time due to the possibility of assisting another resident. 6 of 6 staff interviews conducted stated that R1 had a history of refusing care. Per interviews, there were times when facility staff would show up to assist R1, and they would be already dressed or would refuse their assistance many times. Review of R1’s care log for September 2024 - December 2024 showed R1’s care tasks like escorts and dressing as completed with time and date stamps. Review of R1’s care log also showed documented refusals of care.

Continued on LIC9099C

“Staff had inaccurate record keeping for a resident” – Complaint alleged that facility staff were falsifying R1’s notes stating that R1’s care like dressing and escorting were completed. 6 of 6 staff interviews conducted stated that they keep track of their daily duties on a phone care application. Review of R1’s care log showed that when a task was completed, it would be date and time stamped. Per interviews conducted, if a task is not completed or if a resident refuses care, there is a section in the care application where it can be notated. Interview with Care Services Director stated that if there were incomplete tasks identified, they would be reviewed and flagged by themselves and the Resident Care Coordinator. Review of R1’s care log for September 2024 - December 2024 showed documented refusals of care.

“Staff overcharged a resident for services not received” - Complaint alleged that facility overcharged R1 for care services due to long-term care insurance paperwork not being completed by the facility. Interview conducted with Resident Relations Director stated the following: During a resident’s initial assessment, the facility would confirm if a resident had long-term care insurance. It would be documented in the resident’s care plan on who was responsible for managing the paperwork. If the facility was responsible, then a fee would be charged. Interview conducted with Care Services Director stated that the facility communicated frequently with the long-term care insurance company through phone calls. Interview also stated that the facility did not assist with the paperwork since it was requested to not be included in R1’s care plan. Email correspondence dated 09/04/2024 showed a request was sent to the facility for help with forms from a long term care insurance company. Additional emails provided dated 09/27/2024 showed that a request was made to remove R1’s long term care paperwork from R1’s care plan. Email dated 09/29/2024, showed that the facility did not include assistance with long-term care paperwork to R1’s care plan since it was not established and therefore no care points were added. Interview conducted with involved parties stated that R1’s family was responsible for filling out the long-term care insurance forms.

Based on record review, interviews conducted, and observations made, these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator/Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents.