complaint·November 12, 2025

***CONTINUE FROM 9099*** W1 stated, “R1 had wounds that weren’t healing, and I don’t think staff were changing her dressings the way they should.” W1 reported that R1’s family had expressed concern that her pressure injuries appeared worse over time. During interviews, staff (S1–S4) consistently reported that R1 was admitted to the facility under hospice care with existing pressure injuries. S1 stated, “When she moved in, she already had open wounds, and hospice was coming in daily to do the wound care.” S2 also stated, “We assisted hospice nurses when they came; we didn’t do the wound care ourselves unless instructed.” Review of hospice documentation and care notes showed consistent visits by hospice nursing staff with records of wound care performed per physician orders. During interviews, R2 and R3, both current residents, reported no concerns with staff. Allegation: Staff did not seek medical attention for the resident - Unsubstantiated W1 stated, “When R1 wasn’t eating for a few days, her family wanted her taken to the hospital, but the staff told them no.” According to W1, family members were concerned about R1’s condition and weight loss. Interviews with staff indicated that hospice was overseeing R1’s care plan and directing all medical decisions at the time. S1 stated, “we coordinated closely with hospice daily and updated the responsible party.” S3 added, “The nurse visited regularly and adjusted her plan; the family was aware hospice was managing her care.” LPA reviewed hospice communication notes and progress reports showing regular hospice visits, physician coordination, and documentation of family communication regarding R1’s condition. The records confirmed hospice was aware of the resident’s decreased appetite and continued to provide end-of-life comfort care. Resident interviews (R2–R3) revealed no concerns about staff not providing medical attention when needed. ***CONTINUE ON 9099C*** ***CONTINUE FROM 9099C*** Allegation: Staff does not ensure resident’s electronics are in good repair - Unsubstantiated W1 stated, “R1's TV never worked since she moved in, and every time we asked staff to fix it, they just said they would but nothing ever happened.” W1 reported that the TV belonged to the facility and that R1 spent most of her time in her room without entertainment. During interviews, staff did not confirm that the TV in R1's room was not working. S1 further stated that "the admission agreement specifies the facility does not provide TVs and that R1 brought her own TV. However, if a resident's personal electronics, such as a TV, do not work, staff sometimes assist with repairs as a courtesy". LPA reviewed the admission agreement, which revealed that the facility is not responsible for resident owned electronics or similar amenities. LPA also toured R2 and R3's rooms and facility's common entertainment area. R2 also stated " if I need something, or my TV remote runs out of battery, I have seen staff come and help. Resident's electronics were observed to be in operating condition. This agency has investigated the allegations above. We have found that the allegations were 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.