complaint·November 24, 2025

The investigation revealed the following: Allegation #1-Staff did not address residents’ change of condition. The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected and needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. Staff also stated that residents are checked on every one to two hours a day to assess their condition. The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged. The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), and the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. Additionally, the department did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated . Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Report Continued On LIC9099-C Allegation #2- Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. Staff stated that they believed the resident was going to get medical services for their swollen foot. The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated. The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) but it did not specify that medical services were notified, or any action taken on behalf of the resident. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated . Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the POC due date of 12/05/25 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.