complaint·January 12, 2026

On 01/12/2026, the LPA conducted a subsequent visit and delivered substantiated findings for the above allegation at 9:47AM. At 9:52AM, a physical plant tour was conducted, and no immediate concerns were observed. During today’s visit, the LPA and AA conducted a physical plant tour at 10:25AM, and no immediate concerns were observed. The following was then amended: Allegation: “Staff are not providing reasonable accommodations to resident in care” It was reported that staff did not assist Resident #1 (R1) with obtaining cigarettes or smoking outside and did not accommodate R1’s condition with a reasonable alternative for their call button/pull cord. R1 was diagnosed with incomplete quadriplegia and documented to be bedridden. Individual Service Plan dated 04/17/2025 documented R1’s physical environment to be accessible and safe, with adaptive equipment to aid in their daily activities. This included conducting regular safety assessments, removing potential hazards, and providing necessary mobility aids. It was additionally recommended that the facility coordinate with occupational and physical therapists to assess and implement additional aids that would enhance R1’s comfort and safety. Staff interview revealed that staff assistance with smoking cigarettes is based upon staff discretion and their openness to exposing themselves to the elements. Two (2) caregivers have reportedly been observed to assist R1 in the late afternoon and evenings with smoking which includes holding the cigarette and bringing it to their mouth. Staff reported that R1’s pull cord was wrapped around their arm due to their condition and that R1 did not express any complaints. Staff stated that R1 would often request for staff to wrap the cord around their arm. They further indicated that there were no other alternatives that did not require R1 to be tethered to the pull cord and if there was, it was not their decision to make. Staff also reported that R1 often changed their minds when they made decisions or when they agreed to allow staff assistance, and that R1 was very demanding about their care. Report Continued on LIC 9099-C Interview with R1 confirmed that the facility obtained cigarettes after R1 had provided the facility with money. They also confirmed that staff assisted them once to twice a day in the evenings by going outside and smoking. R1 reported that they only request to go outside for a smoke about twice a day. R1 stated that utilizing the pull cord around their arm is sufficient in the meantime due to the facility not providing other accommodations. R1 raised concerns about the pull cord being accessible only when they are in bed and when their wheelchair is positioned close to the call button system. However, if they were further away, they would not be able to utilize the system and request for staff assistance. Interview with the ED revealed attempts to provide alternatives for R1’s pull cord which included attaching a lanyard to R1’s arm and obtaining a push button pendant. Due to R1’s condition, R1 stated they would not be capable of utilizing a pendant and it was reported that R1 also refused the lanyard alternative. The ED stated that R1 often refused assistance and redirection from staff and frequently changed their mind when they made requests. The ED expressed difficulty with finding accommodations for R1’s pull cord system, but that they were actively working on solving the issue. On 01/13/2026, the facility consulted with a Physical Therapist (PT) to assess R1’s mobility and alternatives to the call system. The PT noted that R1 has some strength for movement in their elbow, hand, and fingers to utilize the pull cord. Furthermore, R1 was confirmed to adequately pull the cord in addition to pushing the button on a pendant to trigger the call system. Based on interview and record review, R1 confirmed assistance with smoking and was provided alternatives to the call system; however, they refused those alternatives and requested for staff to attach the pull cord around their arm. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.