Complaint·May 12, 2026

Allegation: Staff left resident in a soiled brief It was alleged that the staff left R1 in a soiled brief. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that they responded to the facility (9-1-1 call) on 05/03/2026 at approximately 10:00am, and R1 had reportedly complained of stomachache, and when the credible witness assessed R1, they observed R1 was wearing a soiled incontinent brief. During today’s visit, LPA conducted an interview with the Administrator and was informed all residents are checked and assisted with toileting/incontinence care throughout the day and as needed. However, on the date of an incident, there was limited staff available at the facility during the time 911 arrived. Interview with the Administrator also revealed that staff are expected to provide timely assistance with toileting and incontinent care. However, the Administrator was unable to explain as to why on the day of an incident, R1 was not changed and proper care was not provided. Therefore, based on the credible witness observation and Administrator confirmation this allegation is Substantiated . Allegation: Staff did not provide first responder with resident's records It was alleged that on 05/03/2026 staff did not provide a first responder with R1’s records. To investigate this allegation, LPA conducted an interview with the credible witness and was informed that upon arrival (911 call) at the facility, staff #1 (S1) did not appear to know R1’s basic information and were unable to locate or access R1’s facility file. LPA was also informed that it took several minutes for the Administrator to arrive who was able to write down R1’s biographical information before R1 was transferred to the hospital. Interview with the Administrator revealed that S1 was newly hired and did not have access to resident records. During the interview, the Administrator acknowledged that staff should have been able to provide residents basic information and records in a timely manner. Therefore, based on credible witness observation and information gathered during today’s visit, this allegation is Substantiated. Continue on LIC9099-C Allegation: Licensee did not ensure front egress is free from obstruction It was alleged that the licensee did not ensure the front door was free from obstruction. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that when they responded to the facility (9-1-1 call) on 05/03/2026, it was difficult to exit the facility with R1 because there was furniture on the porch and a hose in the way. During today’s visit (upon arrival), LPA observed one (1) chair and one (1) table on the left side of the house (with no obstruction). However, LPA also observed the hose in the way by the ramp. Interview with the Administrator revealed that they placed the chair and the table outside in case residents have family/friends visiting they can sit outside and have privacy. Administrator also acknowledged that the walkway should remain clear and accessible at all times and that items such as outdoor furniture and hoses should not block the front entry, walkway or emergency exits pathway. The Administrator also acknowledge that on 05/03/26 the ramp was an obstructed by the hose and further stated that staff are expected to monitor the facility exterior and remove any items that may interfere with safe passage. Therefore, based on credible witness and LPA observation and information gathered during today’s visit, this allegation is Substantiated. Deficiencies issued during today's visit. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.