It was alleged that staff failed to notify an authorized representative of an incident. Record review of R1's Admission Agreement and Assisted Living Waiver (ALW) documentation revealed that R1 is his own responsible party. No authorized representative was identified in the resident's records; therefore, there was no designated authorized representative for the facility to notify regarding the incident. Additionally, staff interviews revealed that although R1 is their own responsible party, the facility routinely notifies R1's sister and physician when concerns arise regarding R1's health, safety, or well-being.

Allegation: Due to staff neglect resident left the facility unattended

It was alleged that due to staff neglect, R1 left the facility unattended and staff failed to take appropriate action to locate or report him missing. During an interview, S1 reported that R1 frequently leaves the facility independently to visit his wife and typically returns on his own. Staff further indicated that procedures are in place to notify appropriate parties and law enforcement if a resident remains missing for an extended period. During record review, the LPA observed that R1's Physician's Report dated 1/7/2026 indicated that R1 may not leave the facility unattended. However, previous Physician's Reports dated from 2023 through 2025 consistently reflected that R1 was permitted to leave the facility unattended. To clarify, LPA contacted R1's physician during the investigation. The physician confirmed that the restriction noted on the 1/7/2026 Physician's Report was entered in error and stated that an updated report would be completed to reflect that R1 is permitted to leave the facility unattended.

Allegation: Staff do not ensure the residents’ toileting needs are met

It was alleged that staff failed to ensure R1's toileting and incontinence care needs were met. During staff interviews, staff consistently reported that R1 is able to use the restroom independently and generally does not require assistance with toileting. Staff stated that R1 wears pull-ups and frequently refuses personal care, including changing and incontinence care. Staff reported that assistance is routinely offered and provided when accepted by R1. During an interview, R1 expressed no concerns regarding assistance with toileting, incontinence care and stated that staff are supportive and assist him when needed. During interviews, residents R2 through R10 did not express any concerns regarding toileting or incontinence care provided by facility staff. Residents consistently reported that staff are supportive of their needs, provide assistance when requested, and treat residents with dignity and respect.

It was alleged that staff failed to ensure R1 received prescribed medications and that medication needs were not adequately monitored or addressed. During staff interviews, staff reported that medications are routinely offered and administered to R1. Staff stated that R1 frequently refuses his medications and that refusals are documented and reported to the physician. During an interview, R1 reported that staff assist with their medications and stated that they take their medications. R1 did not express any concerns regarding medication administration or delayed medications. During interviews, W1 and W2 did not express any concerns regarding the facility's medication administration practices and did not report concerns that R1 was being denied or not offered prescribed medications. Record review revealed multiple documented medication refusals by R1 on the Medication Administration Records (MARs). Record reviews also revealed documentation of communication between facility staff and R1's physician regarding the medication refusals.

Based on the investigation conducted, which included interviews with staff, witnesses and residents, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.