complaint·September 30, 2025

During their interview, Resident 3 (R3) denied having any knowledge of staff leaving any resident lying on the floor and stated they were not familiar with, nor did they know R1. Per R3, staff is always available to assist them, and they can use their call button to call for help and staff will almost always come to their aid immediately. During their interview, Staff 1 (S1) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 to lying on the floor. Per S1, on August 30, 2025, R1 was upset they had not received a visit from Witness 2 (W2), which lead to R1 throwing themselves on the floor. Per S1, they felt R1 was a threat to themselves and others due to pulling out their own hair and kicking S2. S1 stated they called 911 and R1 was placed on a psychiatric hold. During their interview, Staff 2 (S2) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 lying on the floor. Per S2, on August 30, 2025, staff made the decision to call 911 after R1 slipped from their bed onto the floor and refused to allow staff to assist them getting up. S2 stated they attempted to assist R1 but R1 kicked them, and it was then they and S1 no longer felt safe and called 911. During their interview, Witness 1 (W1) denied R1 informing them, or having any knowledge of staff leaving R1 lying on the floor. W1 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied having any knowledge of staff leaving R1 lying on the floor. W2 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Regarding the allegation Facility staff did not assist resident with hygiene as needed, the following was revealed: It is alleged staff did not assist R1 with hygiene as needed. During their interview, R1 denied the allegation and stated staff assist them with all grooming and hygiene needs. Per R1, at the time of their interview, staff had just assisted them with a bed bath. LPA observed R1 with combed wet hair and a clean appearance. During their interview, Resident 2 (R2) denied having any knowledge of any resident being unkempt and stated facility staff have been and continue to be helpful. Per R2, they initially felt uncomfortable with male caregivers assisting them in the shower, but the staff make them feel safe and they now enjoy and actually look forward to their showers. (Cont. LIC9099-C) During their interview, Resident 3 (R3) denied having any knowledge of any resident being unkempt and stated staff is always available to assist them. During their interview, S1 denied facility staff not assisting R1 or any other resident with hygiene. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. Per S1, R1's hair became disheveled due to R1 running their fingers through their hair and pulling it out. During their interview, S2 denied facility staff not assisting R1 or any other resident with hygiene. Per S2, staff always assist R1 with grooming and bathing and stated that upon R1’s admission to the facility, R1’s hair had been matted, and a brush could not be run through their hair. S2 stated staff have been washing R1’s hair regularly and R1’s hair is now soft enough to brush. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them. During their interview, Witness 1 (W1) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Regarding the allegation Facility staff did not assist resident with incontinence care as needed, the following was revealed: It is alleged staff did not assist R1 with incontinence care as needed. During their interview, R1 denied the allegation and stated staff always assist them with incontinence care. During their interview, Resident 2 (R2) denied having any knowledge of R1 or any other resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care. R2 denied witnessing R1’s or any other residents' appearance to be unkempt. R2 stated facility staff have been and continue to be helpful. During their interview, Resident 3 (R3) denied having any knowledge of any resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care and denied witnessing any other residents' appearance to be unkempt. During their interview, S1 denied facility staff not assisting R1 or any other resident with incontinence care. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. (Cont. LIC9099-C) During their interview, S2 denied facility staff not assisting R1 or any other resident with incontinence care. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them. During their interview, Witness 1 (W1) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W1, they have no concerns regarding the facility and R1 has never shared any concerns with them. W1 stated that as far as they are aware R1 is well taken care of. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W2, R1 had been asked if they were okay with returning to the facility following their hospitalization and R1 had no objections. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff left resident lying on the floor, iff Facility staff did not assist resident with hygiene as needed, or if Facility staff did not assist resident with incontinence care as needed. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.