complaint·November 17, 2025

The investigation revealed the following: Allegation: Staff did not provide adequate care and supervision to a resident. It is alleged that R1 had consumed alcohol and was intoxicated, and staff did nothing to prevent this from happening. LPA reviewed facility House Rules and it is written that residents are allowed to have alcoholic beverages in moderation, within resident rooms, not allowed in common areas. LPA interviewed 4 staff and each denied the above allegation, staff stated that per the house rules residents are allowed to consume alcohol as long as it is in their rooms and in moderation and not taken to the common areas, when residents exhibit chronic issues with alcohol this right may be revoked. LPA interviewed 8 residents and each denied the above allegation and stated they are provided with adequate care and super vision. R1 stated they are able to consume alcohol, drank it in their room and did not take the alcohol out in common areas. Allegation: Staff denied a resident entry to the facility. It is alleged that staff refused to answer the phone or door when R1 was ready to return from the hospital. LPA interviewed 4 staff and each denied the above allegation. Interview with S4 revealed that R1 had been admitted to the hospital during the day and later that evening past 10pm resident was brought back via non-emergency transportation, however, the front door is locked (from exterior coming in only) at 9pm for safety of staff and residents and during that time staff were conducting rounds, S2 observed the non-emergency transportation vehicle and instructed other staff to allow entrance. LPA interviewed 8 residents and each denied the above allegation and stated they have never been denied re-entry to facility after being hospitalized. Per interview with R1 resident stated that they were never denied re-entry but did have to wait maybe 5-10 minutes for staff to open the door as it was after hours and the door was locked. Allegation: Staff did not properly maintain a resident's room. It is alleged that R1’s room has a foul odor and R1’s clothes, bedding and floor was observed to be covered in throw up, urine and feces for over 6 hours as this was observed upon returning from the hospital. LPA interviewed 4 staff and each denied the allegation and stated that rooms are cleaned regularly with a weekly bedding change and deep cleaning, however, if bedding or floors have urine or feces they tend to it right away. LPA interviewed 8 residents and each denied the allegation and stated that staff clean their rooms and bedding is changed weekly. Interview with R1 revealed that upon returning from the hospital the room was clean and bedding was not soiled. (Continued on LIC9099-C) Allegation: Staff exposed a resident to harmful material. It is alleged that when R1 returned to the facility from the hospital R1’s wheelchair still had the bottle of alcohol in it. LPA interviewed 4 staff and each denied the above allegation and stated that although alcohol is permitted at the facility if there is negligent use the alcohol is confiscated. Interview with S4 revealed that although they did not remove the bottle of alcohol from the room, as they were helping with getting the resident care and to the hospital, another staff confiscated the alcohol and this was noticed during a round they made that evening. LPA interviewed 8 residents and each denied the above allegation and stated they have never been exposed to any harmful materials at the facility. Interview with R1 revealed that once they returned to the facility the room was cleaned and alcohol was removed. Allegation: Staff did not ensure a resident attended scheduled appointments. It is alleged that staff are not assisting R1 to their appointments. LPA interviewed 4 staff and each denied the above allegation stating that residents are provided with the proper assistance (if needed) with scheduling appointments. LPA interviewed 8 residents and 5 out of 8 residents denied the allegation and stated that they are assisted with appointments and have not had any issues with this. R1 stated that staff do not provide transportation to their appointments and refused to take them to an appointment, after interview with Staff it was revealed that R1 did not notify staff of the need for transportation to their appointment (which is asked for a 24hr notice), R1 is not able to leave facility unattended and special scheduling was needed as a caregiver would need to accompany R1 and transportation would need to be scheduled, the appointment has been rescheduled and R1’s daughter confirmed that they will be transporting R1 to the appointment. Allegation: Staff did not meet a resident's bathing needs. It is alleged that R1 has gone 3 days without being assisted with showers. LPA interviewed 4 staff and each denied the allegation, stating that residents have a shower schedule and if they are needed with an additional shower one will be provided when as long as a caregiver has the availability. LPA interviewed 8 residents and 6 out of 8 residents denied the allegation and stated they have never been refused assistance with showers by staff. R1 stated that they don’t need assistance with showering/bathing and can do this on their own, they further stated that staff have never refused to assist them with their showers as they have never needed to ask. Based on statements and interviews conducted with staff/residents, and review of client files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur,therefore the allegations are UNSUBSTANTIATED .Exit interview held, a copy of report was provided.