complaint·March 30, 2026

The allegation of “Staff do not ensure resident toileting needs are met in a timely manner” alleges that, facility staff leave residents in soiled diapers for extended periods of time. LPA interviewed facility residents who expressed concerns in the amount of time it takes facility staff to respond to resident’s requests for assistance. Resident #1 (R1) stated that they have been left in a soiled diaper overnight on multiple occasions due to staff not assisting residents at night. LPA interviewed two (2) facility caregivers. The caregivers interviewed stated that their shift ends at 06:00 PM on the days they work and that the facility Administrator provides care to the residents during the night until shift start at 06:00 AM. The facility staff members stated that they do not remain at the facility after their shift ends. One (1) staff member interviewed confirmed that in the past at the start of their shift (06:00 AM) they had observed facility residents in diapers that were soiled during the night and not changed. LPA interviewed the Administrator who stated that they remain awake until 12:00 AM and will perform checks on the residents during the night. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Staff do not ensure resident toileting needs are met in a timely manner” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted. The allegation of “Resident sustained multiple pressure injuries while in care due to lack of care from staff or neglect” alleges that Resident #1 (R1) sustained multiple pressure injuries while under the care of the facility. LPA interviewed R1 who stated that they have one (1) pressure injury on their body that is being cared for, R1 denied the presence of any additional pressure injuries. R1 confirmed that the care for this injury is being provided by a hospice company. Additionally, R1 stated that the injury occurred prior to their arrival at the facility. R1 had no concerns with the care they were receiving for this injury. LPA reviewed R1’s file and observed R1’s hospice care plan to contain wound care orders for the nurse providing care to R1’s pressure injury. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Resident sustained multiple pressure injuries while in care due to lack of care from staff or neglect.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff retained a resident that requires a higher level of care” alleges that the facility retained R1 despite R1 requiring a higher level of care than the facility is licensed to provide. LPA reviewed R1’s physician’s report and did not observe R1 to have any prohibited health conditions listed in their file. R1 informed LPA that they had a pressure injury on their body but care was being provided by a hospice agency. LPA reviewed R1’s file and observed hospice paperwork which confirmed that a hospice nurse was visiting to provide care to R1’s pressure injury. LPA interviewed R1 who expressed that they would like to transfer to a skilled nursing facility (SNF). R1 stated that they would like to receive physical therapy but they were unable to obtain physical therapy at the facility due to hospice interfering with their ability to obtain a physical therapist through their insurance. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of "Staff retained a resident that requires a higher level of care.” Therefore, the allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C. The allegation of “Staff did not adequately address a change in resident's health condition” alleges that the facility did not implement an appropriate change in R1’s care plan following R1’s development of a pressure injury. LPA interviewed R1 who confirmed that the pressure injury was obtained prior to their arrival to the facility. R1 stated that the wound has been getting better while under the care of their hospice nurse. Additionally, R1 denied the development of new pressure sores. LPA reviewed R1’s file and confirmed that wound care was being provided through a hospice agency. LPA interviewed the facility staff and the Administrator who denied R1 experiencing any changes in condition throughout their stay at the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff did not adequately address a change in resident's health condition.” Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of “Staff do not provide resident with adequate food service” alleges that the facility was not providing R1 with adequate meals and was only serving oatmeal for each meal. LPA interviewed R1 who stated that they have a dietary restriction that staff and the facility adhere to. R1 stated that the food served is okay and consists of a variety of meals that conform with their restrictions. R1 had no concerns about the food that was being served to them at the facility. LPA observed sufficient perishable and non-perishable food supplies at the facility. LPA interviewed staff who stated that R1 is on a soft mechanical diet and requires foods to be ground. Staff members interviewed were aware of R1’s dietary restrictions and stated that they adhered to these restrictions when preparing meals for R1. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Staff do not provide resident with adequate food service.” Therefore, the allegation is deemed Unsubstantiated at this time. A copy of the report was printed and exit interview was conducted.