complaint·September 10, 2025

The investigation revealed the following: Allegation: Staff not treating residents with dignity and respect It is alleged that a staff member  has been verbally abusive, calling Resident 7 derogatory names such as "stupid bitch" and using profanity. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not hearing nor witness staff using profanity nor being disrespectful to the residents. A1 states staff must be respectful at all time which is standard practice at the facility. On 07/09/2025 between the hours of 10:00am - 1:58pm. LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42, LPA interviewed (11) residents regarding the allegation. Of the (11) residents: 1 out of 11 confirmed the allegation. 10 out of 11 denied the allegation. 10 of the residents stated the facility it's alright, everyone is treated fair, and with respect. 1 of the resident stated an employee has used inappropriate language and has threatened her. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Report continues on LIC 9099-C Allegation: Staff leave residents soiled for an extended period of time It is alleged that residents are not being changed in a timely manner, resulting in them remaining soiled for prolonged periods. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not aware of residents being left soiled nor not being changed in a timely manner as the facility documents when residents are changed and provided incontinence care. Between the hours of 10:00am - 1:58pm, LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation (1) out of (7) staff confirmed the allegation. Staff states R7 will be assisted with their changing needs by staff and just minutes later R7 will request to have a depends and or diapers changed although the resident is not soiled. Also, its been stated by the staff R7 only wants certain staff to meet her needs and if R7's does not get their way and or needs met immediately, the resident throws food, water and or items at the staff. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm, LPA interviewed (11) residents regarding the allegation. 2 out of 11 confirmed the allegation. 9 out of 11 denied the allegation. Out of the 11 residents:  (4) residents are incontinent and stated staff come quickly to help residents to the bathroom and or help with getting dressed. (5) of the residents stated they do not wear depends nor diapers and are fully independent and is capable of taking care of themselves. (2) of residents who confirmed the allegation, one stated she is not incontinent but just can't walk but as a result of having to wait a long time to be changed or cleaned as of result of that they have had an accident. On 09/05/2025 at 11:35am, LPA conducted a records review and observed the following: On the LIC 602A Medical Assessment for Residential Care Facilities for the Elderly, on page 4 of 9 under the section 1. Overall Physical Health the following physical health status are checked yes: bowel incontinence, bladder incontinence, motor impairment/paralysis (with a history of Cerebrovascular Accident (CVA) and requires assistance with repositioning and transferring due to left side weakness. In the comments it states that R7 had a stroke in 2023 that resulted in left hemiparesis. Since the stroke R7 has been mostly bed-bound occasionally sits up in a wheelchair. On page 5 of 9 on the LIC 602A under the section 2. Capacity for Self-Care d. Able to Care for Own Toileting Needs is checked no which explains due to left sided weakness. On the Face Sheets and Emergency Info form on page 2 of 7 under the toileting section it states full assistance by a caregiver is needed daily with grooming in the morning and at bedtime with two-person assistance. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation: Staff are not answering call buttons in a timely manner It is alleged that there is a delay in staff responding to residents’ call button requests. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1, who denied the allegation, stated that when the facility is alerted by the call light, the protocol requires staff to respond promptly. A1 does not recall any incidents on or around 07/07/2025–07/08/2025 where Resident 7’s (R7) request for assistance was not received in a timely manner. Between the hours of 10:00am - 1:58pm, LPA interviewed seven (7) staff regarding the allegation. Of the (7) staff, 7 out of 7 staff denied the allegation. Of the 7 staff, 2 of the caregiver stated most of the resident's do not use their call light button as most of the resident will yell out for the staff to come assist and or staff caregivers typically conduct 30 minute rounds around the facility to check on the residents. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm,  LPA interviewed (11) residents regarding the allegation. 1 out of 11 resident confirmed the allegation. 10 out of 11 residents denied the allegation. 11 of the residents, 9 stated not using, don't need a call button and or will call out for the staff to assist with their needs. 1 resident stated the staff response when pressing the call button. 1 resident stated the call string from the call button came off so resident yells but the staff still does not respond when she does so. On 09/10/2025 between the hours of 1:53pm - 3:20pm, LPA conducted a tour of the Memory Care Unit (located in Unit 1, Unit 2 and Unit 5) and Assisted Living Unit (located in Unit 3 - Unit 4). LPA observed the following respond time for staff to answer the residents call lights: Room 114 (3:05pm - 3:06pm), Room 201 (3:05pm - 3:06pm), Room 230 (3:11pm - 3:20pm), Room 304 (1:53pm - 2:00pm) and Room 407(3:03pm - 3:04pm). Estimated response time was 7-10 minutes for staff to clear the resident call lights. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Joel Niblett (Administrator) and a copy of the report was provided.