complaint·November 19, 2025

LIC9099-C (Page 2) Allegation: Staff are not following resident’s incontinent plan Finding: Unsubstantiated LPA reviewed R1’s Service Plan dated 05/08/25, which indicates that R1 requires Continence Care six (6) times per day, with care partners completing brief checks every two (2) hours to ensure R1 remains clean and dry. Review of chart notes dated 07/13/25 – 07/17/25 indicates that care partners were performing checks every two hours to reposition R1 and ensure they were clean and dry, as documented. In addition, the staffing schedule confirmed caregiver coverage for the required six-times-per-day continence care schedule. Allegation: Staff are not following resident’s special diet Finding: Unsubstantiated LPA reviewed R1’s Physician’s Order dated 07/02/25, which prescribes a pureed diet with thin liquids. Review of chart notes dated 07/13/25 – 07/17/25 reflects that staff offered R1 foods and liquids consistent with the ordered diet, including soup, yogurt, pudding, mashed potatoes, Cream of Wheat, cranberry juice, and water. Documentation indicates that R1 would eat or drink at times and would occasionally refuse food, which is within resident rights. LIC9099-C LIC9099-C (Page 3) Allegation: Staff did not ensure resident’s hospital bed was set up for resident Finding: Unsubstantiated S1 stated that once they knew that the mattress was delivered they put the mattress in place. LPA reviewed records that showed delivery of DME including mattress was completed on 04/25/25. 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, therefore the allegations is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.