Complaint·November 24, 2025

to be changed. LPA was unable to interview two residents in question that wore diapers as one resident no longer resides at the facility and another resident refused to interview. It is alleged that staff did not respond to residents call for assistance in a timely manner. Interview with 2 of 2 staff stated that residents when they need assistance call out the care staff’s name and/or would use their cell phone to call the facility number and ask for help. Staff stated that staff are making rounds every 10-15 minutes and checking on residents and there is always a staff on each side of the house where they could know when a resident is calling for help. Interview with 2 of 2 residents stated that they always get help when requested and never had issues getting help. It is alleged that Staff did not ensure medication was stored locked and inaccessible to residents in care, specifically to residents’ insulin pen. Interview with staff stated that medication is centrally stored and inaccessible to residents in care. Staff stated that there was one resident that needed insulin, however that resident is no longer a resident of the facility. Staff recall an occasion when residents (R1) was being assisted by staff with changing and giving R1 their insulin pen for them to administer injection and R1 received visitors, and they observed the insulin pen in their bedroom while being assisted. Staff stated pen was removed by staff once it was done being administered and staff finished changing R1. It is alleged that lack of supervision, resulting in resident unclothed in the facility. Record review revealed that resident in question no longer reside at the facility. Interview with 2 of 2 staff stated that there has not been any incident with any resident of the facility being unclothed. Staff stated that none of the residents ever had issues with getting themselves unclothed. Interview with 2 of 2 residents stated that they have never observed any resident being unclothed at the facility. When staff help them get dressed, they are done so in a private setting and with assistance. It is alleged that staff did not ensure that resident’s grooming needs were met. Interview with 2 of 2 residents stated that they get the help they need when they need it at all times. Staff help them get dressed when they need help and do it in a private setting. Staff stated that when residents need to get dressed, change or need assistance with grooming that they help them, but most residents are independent, and they can do it themselves with minimal assistance. Continued on LIC9099-C It is alleged that staff did not provide resident with clean linens. LPA toured the facility and observed a hallway closet full of cleans and sufficient linens for residents. LPA toured the resident bedrooms and observed all beds to have clean linens. Interview with staff stated that they change the residents’ linens twice a week and when necessary. It is alleged that staff did not maintain facility sanitary. LPA toured the physical plant of the facility and observed that upon arrival staff were cleaning the facility. LPA observed staff use cleaning supplies as well as sanitizing supplies. Interview with staff stated that facility gets cleaned in the morning and thorough the day as well as one last cleaning when residents have gone to their bedrooms. It is alleged that facility is malodorous. LPA toured the physical plant of the facility and did not observe the facility to have any malodorous. Interview with 2 of 2 staff stated that R1 had an ileostomy bag and at times when the bag would be drained it would leave a smell for a few minutes, but staff always opened windows to help the smell go away. Staff stated that at times when diapers are changed it can also smell but the smell doesn’t stay or linger in the facility. The smell went away within minutes, LPA at the time of visit observed a staff changing a resident’s diapers and there was a very small faint smell that lasted minimal minutes, once smell was gone the facility smelled fresh from the staff cleaning the facility. Based on the information mentioned above, 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 violations occurred; therefore, this allegations is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.