complaint·November 4, 2025

It is being alleges that the facility staff are not bathing resident in care according to care plan. On 10/24/25 from 8:15am- 9:30 am Interviews were conducted with S1-S9 regarding the allegation above. 9 of the 9 staff interviewed denied the allegation above, 6 of 9 staff stated that residents have baths 2-3 times a week, 3 of 9 staff stated residents have bathes according to their care plan. 9 of 9 staff interviewed stated that when a resident refuses to bathe, it is documented on facility notes. On 10/24/25 from 9:30 am- 12:00 pm interviews were conducted with R2-R8 regarding the allegation above. 3 of the 7 residents interviewed denied the allegation above, 4 of the 7 residents interviewed reported they do not require assistance with bathing. 7 of 7 residents reported they have not gone more than 2 days without bathing. On 11/04/25 LPA conducted a review of the facilities shower schedule as well as a review of R1's Preplacement appraisal dated: 02/20/2024, Service plan dated:07/29/2025, and Physicians report dated:04/23/2025. Per shower log, R1 is schedules to shower 3 times a week. Per Preplacement appraisal dated: 02/20/2024 R1 requires partial assistance with bathing, although R1 prefers to do so on R1's own. Per Service plan dated:07/29/2025, R1 requires assistance with bathing 3 times a week as scheduled. Additionally, service plans states R1 requires heavy reminders and encouragement's to shower, and female staff only is required. Physicians report dated:04/23/2025, R1 is unable to bathe self. On 11/04/25 LPA reviewed facility notes dated 07/09/25 and dated 07/20/25. Notes dated 07/09/25 R1 was observed shaking and out of her norm, staff did not feel comfortable providing shower due to shaking, family was informed that R1 would not be receiving shower. Notes dated 07/20/25 facility notes indicated R1 was shaking shaking while being showered and lost balance but did not experience a fall, family was notified that R1 would not have a shower in the evening. On 11/04/25 LPA attempted to interview R1, however R1 did not wish to be interviewed. Allegation: Staff lock resident out of their bedrooms. It is being alleged that facility staff lock all the doors from the outside of the residents bedrooms in the memory care wing . On 10/24/25 from 8:15am- 9:30 am Interviews were conducted with S1-S9 regarding the allegation above. 9 of the 9 staff interviewed denied the allegation above, 2 of the 9 staff interviewed stated that residents have locked their bedroom doors as it is their right to do so. On 10/24/25 from 9:30 am - 12:00 pm interviews were conducted with R2-R8 regarding the allegation above. 7 of 7 residents interviewed denied the allegation above, and reported having access to bedrooms at all times. On 11/04/25 LPA attempted to interview R1, however R1 did not wish to be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.