complaint·March 3, 2026

Allegation: Staff do not assist resident with toileting. It was alleged that staff failed to assist with toileting during nighttime hours. To investigate, LPA interviewed the Administrator, Staff #2 (S2), a Witness, and three (3) out of five (5) residents who were available. The Administrator and S2 denied the allegation and stated overnight staffing is in place and call lights are monitored with immediate response. Residents interviewed reported staff respond when called and provide assistance without delay. The Witness reported no knowledge of toileting concerns and expressed satisfaction with care. During the visit, LPA observed staff providing toileting assistance to residents in need and noted timely response to call lights. LPA also observed S2 arriving at the facility and relieving the night shift staff (S1) as part of normal staffing operations. Based on interviews and observation, there was insufficient evidence that toileting assistance was denied. This allegation is Unsubstantiated. Allegation: Staff do not ensure that residents’ dietary needs are met. It was alleged that Resident #1 (R1) received low-nutrition meals and that dietary needs were not met. To investigate, LPA interviewed the Administrator, Staff #2 (S2), a Witness, and three (3) out of five (5) residents who were available. The Administrator and S2 stated meals are prepared with appropriate portions and physician-ordered diets are followed. Four (4) out of five (5) residents in care are on special diets, and LPA observed staff providing diet-appropriate meals consistent with dietary orders. Residents reported meals include balanced options and that they are satisfied with food services. The Witness confirmed observing meals and expressed no concerns regarding nutrition. LPA reviewed R1’s physician report and observed that R1 is prescribed a soft and sized-texture diet. During the visit, LPA observed the facility following the physician’s dietary order by providing meals consistent with the required texture and nutritional guidelines. Dietary food served was appropriate for residents on special diets. Based on interviews, documentation review, and observation, there was insufficient evidence to support that dietary needs were not met. This allegation is Unsubstantiated. Continue on LIC 9099C Allegation: Staff do not assist resident with ambulating. It was alleged that staff failed to assist with ambulation and that R1 remained in bed for extended periods. To investigate, LPA interviewed the Administrator, Staff #2 (S2), a Witness, and three (3) out of five (5) residents who were available. The Administrator and S2 stated mobility assistance is provided and residents receive support with transfers and use of mobility devices as needed. Residents reported observing staff assisting with ambulation and transfers. The Witness confirmed awareness of resident care and reported no concerns regarding mobility assistance. During the visit, LPA observed staff assisting residents with ambulation and transfers in a timely manner and noted appropriate support for mobility needs. LPA also observed staff responding promptly to resident requests for assistance. Based on interviews and observation, there was insufficient evidence to support that ambulation assistance was denied. This allegation is Unsubstantiated. Appeal rights explained. Exit interview conducted. Copy of this report signed and delivered.