complaint·February 12, 2026

Between 10:05am – 11:30am, LPA reviewed six (6) residents and three (3) staff members files. LPA also conducted interviews with the Administrator, two (2) staff/Caregivers, and four (4) out of six (6) residents who were able to answer questions. During today’s visit, LPA requested copies of resident and staff rosters. At approximately 9:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. No immediate health and safety issues were identified. Allegation: Staff did not ensure residents care plan was followed. The Reporting Party (RP) alleged that staff did not follow the resident’s discharge instructions and did not schedule necessary follow-up care. The investigation included a review of the resident’s admission documents, care plan, discharge paperwork, and any available documentation related to follow-up appointments or coordination of care. LPA reviewed facility records to determine what actions were taken by staff to implement the resident’s care plan and discharge instructions. During the investigation, the LPA learned that the resident’s wife maintained full control over the resident’s medical appointments and care-related decisions. Interviews and documentation confirmed that the resident’s wife received the initial hospital discharge papers and informed the facility that she would personally schedule all necessary follow-up appointments. Records did not indicate that the facility was responsible for arranging these appointments once the wife assumed that responsibility. The LPA conducted interviews with the administrator, staff, and residents. Staff reported that they followed the resident’s care plan and discharge instructions to the extent applicable and stated that they deferred to the resident’s wife for follow-up scheduling per her request. Staff denied failing to implement required care plan components. Documentation reviewed did not show evidence that staff disregarded the resident’s care plan or failed to act on discharge instructions. Interviews and records indicated that any delays in follow-up scheduling were related to routine coordination processes or the resident’s wife’s control over appointment scheduling, rather than staff non-compliance. Information obtained during the investigation did not provide sufficient evidence that staff failed to implement the resident’s care plan as required. Records and interviews did not conclusively support that neglect occurred or that the facility failed to follow through with necessary care coordination. Based on the information gathered through interviews and record review, the allegation that staff did not ensure the resident’s care plan was followed is not supported by a preponderance of evidence. Therefore, the allegation is determined to be Unsubstantiated. Continue on LIC9099-C Allegation: Resident developed pressure injuries while in care. It was reported that staff failed to reposition a resident every two hours, resulting in the development of two pressure injuries. The Reporting Party (RP) alleged that one wound had healed while one remained open. The investigation included a review of the resident’s Physician’s Report (LIC 602), Needs and Services Plan, and any available skin assessments, wound care documentation, and repositioning records. The LPA reviewed and collected the repositioning log maintained by staff, which documented regular turning and repositioning consistent with the resident’s care plan and physician orders. LPA also reviewed and collected staff training records related to wound care, confirming that staff had received appropriate instruction on wound care procedures and interventions. The LPA also reviewed documentation indicating that the resident was receiving home health wound care services, including assessments and treatment by licensed wound care professionals. During the visit, the LPA was provided pictures of the resident’s healed wounds, which supported that wound care interventions had been implemented and that healing had occurred. The photographic evidence did not indicate neglect or lack of treatment. Interviews were conducted with the administrator, staff, and residents. Staff reported that the resident was repositioned routinely and that wound care instructions were followed. Staff denied missing scheduled repositioning or failing to provide required skin care interventions. No evidence was provided to confirm that staff failed to follow the resident’s repositioning schedule. Based on the information obtained, the investigation did not establish by a preponderance of evidence that facility staff failed to provide appropriate skin care or that the pressure injuries resulted from neglect. The available evidence indicated that wound care was being addressed and treated, and the investigation did not confirm that missed repositioning by staff directly caused the pressure injuries. The evidence was insufficient to prove that the facility’s actions or inactions caused the resident’s pressure injuries. Therefore, the allegation is determined to be Unsubstantiated. Allegation: Staff did not follow residents dietary restrictions. The Reporting Party (RP) alleged that the resident is lactose intolerant and that staff provided the resident with pizza and yogurt, which allegedly caused stomach discomfort. The RP did not provide a specific date for the alleged incident. During the investigation, the LPA reviewed the resident’s Physician’s Report (LIC 602) and Needs and Services Plan. Documentation confirmed that the resident has a lactose-free dietary restriction ordered by the physician. Continue on LIC9099-C The LPA conducted interviews with the administrator, staff, and residents. Staff denied providing foods inconsistent with the resident’s dietary needs and stated that meals are prepared according to physician-ordered restrictions. Residents interviewed did not report concerns regarding meals or dietary accommodation. The LPA was also provided pictures of meals served to the residents. Upon review, the photos confirmed that the meals provided were consistent with the resident’s lactose-free dietary order and did not contain dairy products. Based on interviews, record reviews, and photographic evidence, the information obtained did not verify that staff provided foods inconsistent with the resident’s documented dietary restriction. The investigation also did not confirm that the alleged meal incident occurred as reported. Because there was no corroborating evidence confirming that staff violated the resident’s dietary restrictions, the allegation is determined to be Unsubstantiated. Allegation: Staff are operating beyond the terms and conditions of the license. Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit to address the allegation that the facility was caring for three bedridden residents while the facility license permitted only one bedridden resident. During the visit, the LPA conducted a full physical walk-through of the entire facility, including all resident rooms and common areas. No residents observed met the regulatory definition of bedridden. The LPA also reviewed all resident files, including current Physician’s Reports (LIC 602) and Needs and Services Plans. Based on the documentation reviewed, no residents were designated as bedridden at the time of the visit. Additionally, the LPA conducted interviews with the administrator, staff, and residents. All individuals interviewed denied that the facility had ever admitted or cared for more than one bedridden resident at any time. The investigation further included a review of the facility’s bedridden approval and any licensing limitations related to bedridden care. Information obtained did not indicate that the facility exceeded its licensed bedridden capacity or operated outside the terms and conditions of its license. Based on the information gathered through record review, interviews, and direct observation, the allegation that the facility was operating beyond the terms and conditions of licensure could not be confirmed. Therefore, the allegation is determined to be Unsubstantiated. Continue on LIC9099-C Allegation: Staff do not practice safe transfer methods with residents in care. The Reporting Party (RP) alleged that on 12/05/2024, staff transferred a resident from bed to wheelchair by lifting the resident manually instead of using a Hoyer lift and transferring the resident to a gurney for a medical appointment. The investigation included interviews with the administrator, staff, and residents. Staff acknowledged that a Hoyer lift was not used during the transfer in question; however, all staff interviewed stated that the resident was transferred safely and no injuries or adverse outcomes were reported. The LPA reviewed staff training records, which confirmed that staff had received appropriate and current training on safe transfer techniques, including the proper use of mechanical lifts and other assistive devices. Staff confirmed knowledge of safe transfer procedures during interviews. The LPA also observed transfer equipment on site, including a Hoyer lift and other assistive devices, and reviewed facility procedures related to resident transfers. No evidence was found indicating that staff required equipment or failed to follow established transfer protocols. Although the Hoyer lift was not used, evidence supports that the resident was transferred safely, and staff had the appropriate training to perform transfers. There was insufficient evidence to establish that the alleged unsafe transfer occurred as described. Based on interviews, record reviews, and observations, the allegation that staff do not practice safe transfer methods with residents is not supported by sufficient corroborating evidence. Therefore, the allegation is determined to be Unsubstantiated. No Deficiency issues during today's visit. Exit interview conducted and copy of this report signed and delivered.