Complaint·September 4, 2025

***report continues from LIC9099*** On 11/21/24 R1 was placed on Hospice and on 2/19/25 R1 moved to Memory Care for the last time. R1 was discharged from the facility on 3/17/25 to a 6 bed RCFE operated by W1. S1, S2 and W2 all stated that R1’s health was in decline during her time at the facility. Allegation: Resident sustained unexplained laceration W1 was concerned about the open sores on R1’s heels and considered them to be a laceration. W2 stated that staff were monitoring the condition of R1’s heels on a daily basis. Staff would try to get R1 to lie in bed with her feet elevated so the heels were not in contact with the bed sheets, but she often refused. W2 also stated that she would not consider the sores on R1’s feet to be unexplained laceration. Allegation: Staff did not seek timely medical treatment for resident W1 had no specific information regarding this allegation stating that she “had a feeling” that the residents at the facility were being neglected and that it should be investigated. During the time period outlined in the complaint R1 was on Hospice and receiving regular visits from the Hospice nurse (W2). W2 stated that she was in contact with R1’s physician as needed and felt that R1 received all the medical care she needed in a timely manner. Allegation: Staff are not providing adequate assistance to resident during feeding times W1 never observed R1 during mealtimes but did observe food on her mouth and clothing. S1 and S2 state that R1 would often refuse to eat or eat very little. LPA reviewed R1’s care notes from January 2025 to March 15, 2025, and saw several entries stating that “R1 didn’t eat much,” and “R1 refused breakfast.” Allegation: Staff are not properly supervising residents who may be a fall risk W1 stated that on one of her visits to the facility she found R1 lying in bed with both legs hanging on the left side of the bed with no supervision and the bedroom door shut. S2 stated that residents in the Memory Care Unit who are identified as a fall risk are put on an increased level of supervision, these residents are checked hourly or more as needed. R1 was considered a fall risk and care notes reviewed by LPA document that staff were checking on R1 on a regular and routine basis and would occasionally find R1 trying to get out of her bed or wheelchair in the same manner as described above. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: Staff are not meeting residents’ dietary needs W1 stated that between her visits to the facility it appeared that R1 had lost weight, and she felt that the staff weren’t monitoring R1 close enough during mealtimes to ensure that she eats her food. W1 asked facility staff, names unknown, about R1’s diet and staff replied that R1 doesn’t eat much and that they try their best, but they can’t force her to eat. S2 stated that R1 had a very poor appetite and that she often would refuse to eat. S2 also stated that staff would offer R1 dietary supplement drinks which R1 would drink occasionally. This agency has investigated the above complaints. We have found that the complaints are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.