complaint·January 13, 2026

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff lost resident's diapers . The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Exective Director Melanie Washington. A copy of the report and Appeal Rights were provided. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that they have not heard of a resident being left in a soiled diaper. Regarding the allegation, staff are not following physicians orders for oxygen, the following has been concluded: It was alleged that staff were not following R1's physician orders for oxygen. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. However, only two out of the eight residents interviewed reported using oxygen while at the facility. Both of those residents denied the allegation and stated that they have not had any issues with their oxygen while at the facility. The Department conducted four staff interviews. Four out of the four staff interviewed also denied the allegation. Regarding the allegation, staff do not make the food accessible to resident, the following has been concluded: It was alleged that staff did not make food accessible to R1. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and denied having any issues with accessing food. The Department conducted four staff interviews. Four out of the four staff interviewed also denied the allegation. Regarding the allegation, residents sheets are not being changed timely, the following has been concluded: It was alleged that R1's sheets were not being changed timely. The Department was unable to conduct an interview with R1 for this complaint due to R1 no longer residing at the facility. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported no issues with their sheets not being changed timely. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and reported not hearing any issues with residents sheets not being changed timely. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Melanie Washington and a copy of the report was provided.