complaint·April 18, 2025

On the allegations “Improper eviction” “Resident needs are not being meant” “Staff left resident in soiled diaper” “Facility is not providing services that are being charge” “Facility is not proving resident proper meal” “Resident is being isolated” “Resident room is being used as staff break and or storage room” “Facility is short staffed” the following was found: On 01/14/2025, LPA conducted interviews with R1 and the Executive Director at the time Niare Feaster (ED), reviewed documentation including R1’s admission agreement, care plan dated 10/13/2023, physician’s report dated 04/18/2024, facility billing records, eviction notice, and staff schedules. Facility observations were also conducted. R1 stated they feel there are not enough staff and expressed a desire for more one-on-one interaction, including being accompanied to the activities area every Wednesday at 1:00 PM. R1, who identifies as largely independent, shared they self-administer medication and often decline bathroom assistance. They clarified they do not receive diapering services as part of their care plan and care plan reflects that they do not require incontinence care. R1 reported requiring nighttime toileting assistance due to wheelchair access challenges. R1 also shared concerns about having occasionally forgotten to request meals, resulting in limited options such as toast or pie. R1 expressed dissatisfaction with being billed for services such as oxygen management and bathing, which they believe are not provided. Review of records showed R1 was admitted on 10/13/2023, with a base rate of $7,413.00 per month. The total amount billed through February 2024 was $46,630.62 including late fees, with only two successful payments made since admission, as reflected in the payment history. The ED explained that the oxygen service billed is the facility’s base rate for residents with oxygen, which includes documentation but no hands-on management or intervention. ED stated that toileting assistance remains on the service plan, however R1 seldom uses it and has declined its removal. Report continues on LIC9099-C Continued from LIC9099-C Regarding the eviction, a 30-day notice to quit was issued on 02/02/2024 for non-payment of rent. Staff schedules for February and March 2024, were reviewed by LPA and LPA observed that enough staff were scheduled. LPA also observed an adequate amount of staff at the time of both visits. While R1 reported feeling that more staff would improve their experience, interviews and documentation confirmed no lapses in care or supervision. Observations conducted during the facility visit found R1’s room appropriately maintained and free of any signs it was being used for staff breaks or storage. There were no indications of inappropriate use of the resident’s private space. There was no evidence to support the allegation that staff left R1 in a soiled diaper, and this is further unsupported by the fact that R1 does not receive diapering assistance as part of their care plan. Regarding meals, kitchen staff reported that residents must request meals outside of scheduled times and that snacks, including pie, are available when full meals are not requested. R1 stated that they do forget to order meals sometimes and only wants toast or other small items from the options available. Finally, R1 stated that they remain in their room by choice due to pain and mobility limitations and may request assistance to participate in activities. ED did inform LPA that while staff provide escorts to R1 when available if they would like that to be apart of their care plan it would be an additional charge. Based on interviews, record review, and observations the above allegations are UNSUBSTANTIATED 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 .