complaint·July 2, 2025

Allegation: Staff did not assist resident with care needs in a timely manner. The complaint alleges that a resident has been neglected, specifically claiming that they have been unable to use the bathroom and have had to sit in their urine. On July 2, 2025, between 10:00 AM and 1:00 PM, the Licensing Program Analyst (LPA) interviewed six staff members (S1-S6), all of whom denied the allegations and stated that they provide care for all residents. Staff members S5 and S6, who primarily assist resident #1 (R1), also denied the claims, asserting that R1 has not been neglected and has not been left sitting in urine or unable to use the bathroom. LPA additionally interviewed the Assistant Director of Staff Development (ASSD), who denied the allegations and explained that all three shifts routinely perform incontinent services every two hours or as needed. R1 is scheduled for diaper changes every two hours or as needed. Later, on July 2, 2025, between 1:30 PM and 2:30 PM, LPA interviewed five residents (R1-R5). Four out of five residents denied the allegations, stating that staff regularly change their diapers and assist with their activities of daily living (ADLs). They also reported that when they pull the alarm cord, staff usually respond within two to four minutes. Report continued LIC9099-C A review of the Caregiver Daily Flow Sheet and staff notes for residents' ADLs, dated July 01 to July 02, 2025, confirmed that R1 receives daily assistance unless R1 refuses. LPA reviewed the Nursing-issued 24-hour report dated June 22 to June 29, 2025, which showed that R1 refused staff assistance very often. Furthermore, on July 2, 2025, the LPA pulled the alarm cord in R1's room, and staff arrived to assist within two minutes. The LPA also observed that the residents looked well-groomed and clean, and they did not appear to be neglected. Based on the information collected from the facility inspection, observations, interviews, and records analysis, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to Executive Director Joel Niblett.