complaint·November 19, 2025

CONTINUED FROM FORM LIC9099 Resident R1 was admitted to the facility on 03/31/2007 and discharged from West Glenn Manor in May 2024 after he was assessed to require a higher level of care. R1 was on the Assisted Living Waiver. Based on multiple physician reports reviewed, the latest of which was established on February 23, 2022, R1 was ambulatory and able to leave the facility unassisted, with a primary diagnosis of Major Depressive Disorder. R1 was not assessed to have any form of Major Neurocognitive Disorder at the time. Regarding the allegation that Staff do not properly groom a resident while in care , the following has been concluded: Based on multiple staff and witness interviews, it was determined that R1 required extensive assistance with toileting and grooming care. Staff interviews conducted all confirmed that facility staff was providing R1 with assistance with these activities of daily living. R1 was stated to have grown reticent to receive showers or change clothing during the final years of his admission at the facility, requiring additional prompting and occasionally being stated to have yelled at staff attempting to provide assistance. Regarding the allegation that Resident is being over fed while in care , the following has been concluded: Based on a wide majority of statements gathered, it was determined that facility staff was providing meal supervision to R1 while on the premises, however meals at the day program attended were not as closely monitored, resulting in R1 allegedly requesting to finish the plates of other program clients. Additionally, R1 was found to procure food in the community on a frequent basis as well. Weight gain observed during the resident's admission can therefore not be directly attributed to staff failing to supervise R1 adequately. Regarding the allegation that Staff are not addressing a resident's medical conditions while in care , the following has been concluded: A review of the resident's assessments and charting notes, frequent follow-ups with R1 primary care provider, behavioral specialist as well as hospitalization reports appears to document that medical conditions experienced by R1 were monitored and medical attention was sought whenever needed. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff are not meeting a resident's incontinence needs , the following has been concluded: Based on staff interviews and assessments reviewed, it was determined that R1 was occasionally experiencing diarrhea episodes which required the use of incontinence supplies, however it was not a continuous need. Charting notes and physician visit reports dated December 2021 indicate that R1 suffered more frequent episodes while at program which appear to be related to R1's food intake while out of the facility. It cannot be confirmed whether the reported occurrence of a soiled diaper happened during one of these episodes rather than as a result of facility staff failing to ensure R1 was changed in due time. As a result, all four allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is no preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.