complaint·December 18, 2025

Page 2 Staff did not allow resident to seek medical attention. - UNSUBSTANTIATED It was reported that a resident who was not feeling well wanted to go to the hospital and staff did not arrange for the resident to go to the hospital. LPA reviewed care plan for Resident 1 (R1) which states that R1 is on hospice. The care plan states the supervisor will contact the hospice RN manager and the responsible party as needed. In case of emergencies not related to hospice care (e.g., severe bleeding or injury), staff are to call 911, notify hospice, and inform the responsible party. The Emergency Protocol states that staff will contact hospice for any issues related to the resident’s hospice care. ED stated Resident 1 (R1) is on hospice and the hospice nurse would be called if R1 was not feeling well. Any time the facility has tried to send R1 out to the hospital they have refused to go. This allegation is unsubstantiated. Licensee does not ensure staff are receive adequate training.- UNSUBSTANTIATED It was reported staff are not properly trained in how to assist a resident with a transfer from a wheelchair to the bed LPA reviewed the “New Hire Training Check-Off Sheet” which documents the initial training topics that all new hires undergo when they start working at the facility. Topics include Mobility & Safe Transfers and Bending and Lifting Techniques. ED stated new staff have 20 hours of video training before they start working with residents and they get an additional 20 hours hands on training and shadowing. This training is documented. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Facility is not following a resident’s care plan. - UNSUBSTANTIATED It was reported staff do not maintain record of resident’s bowel movements. LPA reviewed care tracking sheets for two residents for the month of October 2025. The tracking sheets document bowel movements on all days of the month for all shifts. Both tracking sheets are filled out correctly for both residents. ED stated this is part of each resident’s care plan and staff chart it daily This allegation is unsubstantiated. This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.