complaint·February 9, 2026

investigation, including, but not limited to staff and resident roster, residents’ physician’s report, admissions agreement, appraisals, need and service plan and other documents. After the initial visit, LPA requested and received R1’s medical records from the hospital, and they were reviewed on February 3, 2026. Allegation #1: Staff did not seek timely medical attention for resident. It was alleged that facility staff did not seek medical attention in a timely manner for resident #1 (R1’s) altered mental status. LPA review of R1's file revealed the following: R1 was assessed and admitted to the facility on October 15, 2025; LPA interview with executive director (ED) and other staff revealed that R1 and all the residents are receiving adequate care and supervision by facility staff, and that 911 emergency service calls are made by staff if necessary. LPA interviews with thirteen (13) out of eighty-one (81) residents state that staff provide satisfactory care and supervision. R1’s physician's report does not identify that R1 had altered mental condition. A review of hospital medical records also did not provide any information to support the allegation. Therefore, based on LPA interviews and record review, the allegation is Unsubstantiated at this time. Allegation #2: Staff neglect resulted in resident developing a pressure injury. It was alleged that R1 developed a pressure injury while in care at the facility. ED and other staff indicated that R1 had no pressure injuries. A review of R1’s facility file and hospital records did not provide any information to verify that R1 developed pressure injuries. There was no indication that R1 developed any pressure injury. The information available during this investigation does not verify the allegation. Therefore, based on interviews and record review and due to lack of supporting evidence, the allegation is unsubstantiated at this time. Continue to LIC 9099-C Allegation #3: Staff did not ensure resident received adequate nutrition. It was alleged that the facility was not providing adequate nutrition for R1 which led to R1 losing weight. During LPA’s visits, it was observed that the facility offers a well-balanced, nutritious meal throughout the day with various options. During interviews with staff, all staff stated they not only fed the residents and provided the same meals as everyone else but also offered additional food according to residents' preferences and dietary restrictions. Staff always encourage and assist residents to finish their meal. During interviews with residents, all residents stated they are served three (03) meals a day and that snacks are available throughout the day. During an interview with a third-party witness, they stated that residents loved the food at the facility and did not suspect any malnutrition or inconsistencies while visiting the facility. A review of the R1 medical records from the hospital did not indicate that the resident was malnourished. Based on interviews, observations, and record review, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Allegation #4: Staff did not ensure comfortable living accommodations were provided for resident. It was alleged that staff do not provide comfortable living accommodation in R1's bedroom. R1 resided in bedroom #12, and it was observed that R1 had all required furniture. Everything was functional and comfortable. LPA's observation of other residents bedrooms revealed that the facility residents have preferences for their living accommodations and staff is trying to accommodate them to the best of their ability. LPA interview with the staff revealed that every resident has their own preferences and up to date they have not received any complaints from any resident about their living arrangements. Residents revealed that they did not have any problem with the living accommodation in their respective rooms. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of this report was given to the Wellness director (S2).